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IMAGE  EVALUATrON 
TEST  TARGET  (MT-3) 


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1.0  ;^K£  1^ 


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11.25 


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U    11.6 


Hiotographic 

Sciences 
Corporation 


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^-^  W?ST  MA!N  STRUT 

WEB»r*'x,  N.Y.  US80 

(716)  •72-4S03 


Q"  -^     "^^  ">> 


CIHM/ICMH 

Microfiche 

Series. 


CmM/ICMH 
Collection  de 
microfiches. 


Canadian  Institute  for  Historical  Microreproductions  /  Institut  Canadian  de  microreproductions  historiques 


Tdchnical  and  Bibliographic  Notas/Notes  tachniquas  at  bibiiographiquas 


Tha  Instituta  has  attamptad  to  obtain  tha  baat 
original  copy  availabia  for  filming.  Faaturas  of  this 
copy  which  may  ba  bibliographically  uniqua, 
which  may  altar  any  of  tha  imagas  in  tha 
raproduction,  or  which  may  significantly  changa 
tha  usual  mathod  of  filming,  ara  chackad  balow. 


D 


D 


D 


n 


n 


Coloured  covars/ 
Couverture  da  coulaur 


I      I    Covers  damaged/ 


Couverture  endommagie 


Covtirs  restored  and/or  laminated/ 
Couverture  restai/'6e  et/ou  pellicul6e 


I      I    Cover  title  missing/ 


Le  titre  da  couverture  manque 


I      I    Coloured  maps/ 


Cartes  g^ographiquas  en  couleur 

Coloured  ink  (i.e.  other  than  blue  or  black)/ 
Encre  de  coulaur  (i.e.  autre  que  bleue'ou  noire) 


I    71    Coloured  plates  and/or  illustrations/ 


Planches  et/ou  illustrations  en  couleur 

Bound  with  other  material/ 
Reli6  avec  d'autres  documents 

Tight  binding  may  cause  shadows  or  distortion 
along  interior  margin/ 

La  reliure  serr^e  peut  causer  de  I'ombre  ou  de  la 
distortion  le  long  de  la  marge  intirieure 

Blank  leaves  added  during  restoration  may 
appear  within  the  text.  Whenever  possible,  these 
have  been  omitted  from  filming/ 
n  se  peut  que  certaines  pages  blanches  ajouttas 
lors  dune  restauration  apparaissent  dans  la  taxte, 
mais,  lorsque  cela  6tait  possible,  ces  pages  n'ont 
pas  M  film^es. 

Additional  comments:/ 
Commentaires  suppl^mentaires; 


Tha 
toti 


L'Institut  a  microfilm*  le  meilleur  exemplaira 
qu'il  lui  a  iti  possible  de  se  procurer.  Les  details 
da  cat  axamplaira  qui  sont  peut-Atre  uniques  du 
point  de  vue  bibliographiqua,  qui  peuvent  modifier 
una  image  raproduite,  ou  qui  peuvent  exiger  une 
modification  dans  la  mithoda  normale  de  filmage 
sont  indiquAs  ci-dessous. 


r~~|    Coloured  pages/ 


Pages  de  couleur 

Pages  damaged/ 
Pages  endommag^as 


□    Pages  restored  and/or  laminated/ 
Pages  restaurias  et/ou  pellicul6es 


Tha 
poai 
of  tl 
film 


Orifl 

bag! 

th« 

aion 

oth< 

first 

aion 

oril 


V 


D 


Pages  discoloured,  stained  or  foxed/ 
Pages  d^colories,  tachat^es  ou  piqudes 


I      I    Pages  detached/ 


Pages  ditachdes 

Showthrough/ 
Transparence 

Quality  of  prir 

Quality  in^gale  de  I'impression 

Includes  supplementary  materia 
Comprend  du  material  suppl^mentaire 

Only  edition  available/ 
Seule  Edition  disponible 


r~/|  Showthrough/ 

I      I  Quality  of  print  varies/ 

I      I  Includes  supplementary  material/ 

I      I  Only  edition  available/ 


Tha 
shal 
TINI 
whi( 

Mar 

diffi 
antii 
bagi 
righ 
raqu 
mati 


Pages  wholly  or  partially  obscured  by  errata 
slips,  tissues,  etc.,  have  been  refilmed  to 
ensure  the  best  possible  image/ 
Les  pages  totalement  ou  partiellement 
obscurcies  par  un  feuillet  d'errata,  une  pelure, 
etc.,  ont  6ti  filmies  A  nouveau  de  fapon  d 
obtenir  la  maillaure  image  possible. 


This  item  is  filmed  at  the  reduction  ratio  checked  below/ 

Ce  document  est  film*  au  taux  de  reduction  indiquA  ci-dassous. 

10X  14X  18X  22X 


/ 


12X 


16X 


20X 


26X 


30X 


n 


24X 


28X 


32X 


Tha  copy  fiimad  h«r«  ha*  b—n  r«produc«d  thanks 
to  tha  ganarosity  of: 

University  of  British  Columbia  Library 


L'axamplaira  film*  fut  raproduit  grica  i  la 
gAnArotitA  da: 

University  of  British  Cc<umbia  Library 


Tha  imagae  appaaring  hara  ara  tha  bast  quality 
poasibla  consldaring  tha  condition  and  lagibility 
of  tha  original  copy  and  in  kaaping  with  tha 
filming  contract  spacifications. 


Original  copiaa  in  printad  papar  covara  ara  filmad 
baginning  with  tha  front  covar  and  anding  on 
tha  last  paga  -.vith  a  printad  or  illuttratad  impras- 
sion,  or  tha  back  covar  whan  appropriata.  All 
othar  original  copiaa  ara  filmad  baginning  on  tha 
first  paga  with  a  printad  or  illustratad  impraa- 
sion,  and  anding  on  tha  last  paga  with  a  printad 
or  illustratad  imprassion. 


Tha  last  racordad  frama  on  aach  microficha 
shall  contain  tha  symbol  •-^-  (maaning  "CON- 
TINUED"), or  the  symbol  Y  (maaning  "END"), 
whichaver  applias. 


Las  imagas  suivantas  ont  AtA  raproduitas  avac  la 
plus  grand  soin.  compta  tanu  da  la  condition  at 
da  la  nattatA  da  l'axamplaira  film*,  at  an 
conformiti  avac  las  conditions  du  contrat  da 
fllmaga. 

Las  axamplairas  originaux  dont  la  couvartura  an 
papiar  ast  imprimia  sont  filmAs  an  commandant 
par  la  pramiar  plat  at  an  tarminant  soit  par  la 
darnlAra  paga  qui  comporta  una  amprainta 
d'imprassion  ou  d'illustration.  soit  par  la  second 
plat,  salon  la  cas.  Tous  las  autras  axamplairas 
originaux  sont  filmAs  9n  commandant  par  la 
pramiAra  page  qui  comporte  une  empreinte 
d'impression  ou  d'illustration  at  en  terminant  par 
la  derniAre  page  qui  comporte  une  tella 
empreinte. 

Un  des  symboles  suivants  apparaltra  sur  la 
darnlAre  image  de  cheque  microfiche,  seion  le 
CBs:  le  symbole  — ^  signifie  "A  SUIVRE",  le 
symbols  V  signifie  "FIN". 


Maps,  plates,  cherts,  etc.,  may  be  filmed  at 
different  reduction  ratios.  Those  too  large  to  be 
entirely  included  in  one  exposure  ere  filmed 
beginning  in  the  upper  left  hand  corner,  left  to 
right  and  top  to  bottom,  as  many  frames  es 
required.  The  following  diagramit  illustrate  the 
method: 


Les  cartes,  planches,  tableaux,  etc.,  peuvent  Atre 
filmAs  A  des  taux  de  reduction  diffArents. 
Lorsque  le  document  est  trop  grand  pour  Atre 
reproduit  en  un  seui  clichA,  il  est  film*  A  partir 
de  Tangle  supArieur  geuche,  de  gauche  k  droite, 
et  de  haut  en  bas,  en  prenant  le  nombre 
d'images  nAcessaire.  Las  diagrammes  suivants 
iiiustrent  la  mAthode. 


1 

2 

3 

1 

2 

3 

4 

5 

6 

DISEASES 


OK    I  UK 


Nose  ^.nd  Throat 


\ 


J.  I'KICK-iJROW.X,  M.B.,  IJ<.(MM:. 

«iMi>    llo.iir*,,.    Laim.%.;oi.o.;i.t   to  tmk   l'i„>,KsT<.vr   Oki-iiaxV    ir„M,      Kki  i..w   <„    ruy 

A-KH.,..v    I,...v.s,..„...„„..    «„,>„. .„,.   ,M.  .,r.,...H....,    S,.,,  V.    M.     *. 

".'  T.I,:  l.,.,T„„  Mkdmm,  A.,».ur,.,N.  t.,k  I-.x-Amk,,,,  „  M,...,-., 
(.■.>.m:kk,^,   tmk  <'*.v*i.riM    MKi.ir,,,.   a»»hi..ii.,.>,    riiK 

D.NTllUi.    MKI.1.  «l     ASSCK  lATKlS.    KTl'..    KTI 


Illustrated  with  .59  Engravings.  !ncludlng  6  Full-page 

Color-plates  and  q  Color-cuts  in  the  Text, 

many  of  them  Original 


3ir 


'^iiii..- 


i'Hir..\r)Kr,nri\.  \k\\   v..i;k,  dit.  A(i.. 
TlIK  K   A.    DAVIS  COMPANY.   PriUJSHEKS 

19(K) 


CUPVKIUIIT,  I90U. 

BY 

THE  V.  A.  DAVIS  COMPANY. 


I  Kegi>'t«reil  iit  Stntloiiers    Hall.  I^>nili>ii,  Kii; 


l*liiliidel|ihia,  P«..  V.  S.  A. : 

The  Medital  Bulletin  PrititiiiK-liniise, 

1111 1-IC  Chun-)  Street. 


V'S\ 


IN   l.'KCOdMTloN   OF  HIS   UNTIKINci    KNi:i{(iV   IN  TM|.: 
INVMSTKiATIOX  OF  SCUFNTIFIC  TIM  Til 

HIS   FMINFNT  SKKVICKS  IN  TIIK    \l>\  ANCF.M  FN  I    OF 

LARYNGOLOGY  AND  RHINOI.OGY 
THIS  VOLUMH 

n 
Al'KKi  TI(»N.\TKI.Y    DkiHi  a  IKIi 

TO 

PROF.  E.  L  SHURLY,  M.D., 

■ir 
Ills  SINCKliF   FiilFNK: 


THH  AUTHOR. 


ri{Ki-Aci<:. 


In  Jildiiij,'  (iiif  iiMMv  |i.  the  Inii^r  1,^1  ,,1  u.uk.-,  llial  liiiM'  Ix.'uii  j)ulj- 
li.-litd  iiiM.ii  iliscascs  nl"  Hi,,  nose  iiiid  tlin.at  tlu'  iiiithor  is  iiwHrc  that  lie 
iias  iiiKlcrtakcn  iicillior  a  li^^lil  ikh-  aii  irri'sponsihlt'  task;  and  wcro  it 
not  Jur  llic  fact  that  tlu-nj  is  a  ])i»)l"  siuiml  field  in  a  hir-;c  mcasiirt'  still 
linon  ii)Hc<|  lie  would  not  have  vciiliind  to  present  to  the  mtdiiii!  piililic; 
lUiotluT  Noiiiiiii'  upon  this  suhjccl. 

■*.^  ii  pnicliiioiicr  ulio  foi'  nearly  iwenty  \r,ir>  was  eiii^aired  in  ^'eii- 
<'ral  1)111(1  ICC,  an<l  who  for  the  last   ten  _veai>  ha-  devoted  hiin>elf  ex- 
••lusncly  lo  nose-and-tliroat  work,  he  ha.-  fre(iiieiill_v  been  struck  witli 
the  small  aiiKUinl  of  knowledjie  possoMd   \,\  the  jirid'ession  at  largo 
upon  tli(   diseases  of  these  iiiijiortant  or-ans.     Tatients  are  sent  to  the 
speeiali-l  n|'  acknowledged  skill,  hy  i)hysieian-  of  towns  and  cities  far 
renioi..  in, in  iIk   residence  of  the  speeiali>t  himself.     I'.iit  these  patients 
are  the  Inriiiiiale  few:   those  who  have  coiiifortahle  lioines  with  all  that 
gooil  lo(d.  kind  friends,  and  liygieiiie  surroundings  can  do  to  re.-tore 
them  tn  health,  a>  well  as  means  i..  pay  the  sjieeialist  whose  serviiT.s 
Ihey  re(piirc.     What  ahoiit  the  larger  nunihery   the  imju'cunious?   the 
}K)or?  Iho.-e  who  might  pay  a  small  fee  for  relief  from  constant  siill'er- 
ing,  hut  who  are  iimihle  to  make  hmg  journeys,  and  to  meet  the  obliga- 
tions rtupiircd   hy  staying  in   the  city  and   remunerating  the  laryn- 
gologist  for  liis  work?     It  is  for  physicians  and  surgeons  who  so  fre- 
quently iiiict  patients  of  this  class  and  for  students  preparing  for  the 
regular  practice  of  their  prcd'ession  that  this  hook  is  written. 

In  this  rushing  age,  when  a  thousand  and  one  things  demand  the 
attention  of  the  Inisy  praelitioiu-r,  any  work  of  this  kind  to  he  of  real 
nise  must  he  terse  and  to  the  poiid.  At  the  Siime  lime,  when  the  j)ro- 
fcssion  is  overcrowded,  and  the  ]diysician's  fees  often  small  and  dilli- 
cult  to  eollect.  a  large  jiricc  for  a  hook  is  often  out  of  the  question. 
'lo  meet  these  re«iuirenients  in  a  reasonahle  ami  candid  way  lias  heen 
the  author's  aim. 

Jn  order  to  do  this  he  has  left  out  certain  subjects  which  are  n.su- 
ally  considered  to  belong  to  this  specialty.  For  this,  however,  there  ia 
ample  reason,  as  some  of  these  are  dealt  with  in  works  on  general  medi- 
cine, and  others  in  works  on  ophthalmology  and  otology.  This  may 
be  said  of  descriptive  anatomy  of  the  nose  and  throat,  which  is  touched 

(V) 


VI 


I'liKT  \ri:. 


ll|Mi|l  ii|||\  .11  liir  i|>  ll  I'clilli'.  In  llli  |i|';li'l  Kill  I  ri'ilt  IIK'lll  n|'  illsriisc:  ,,\' 
tllCSC  nririlMS.  I>i>('l|srs  ul'  lllr  Ircillljll  >lllll>  ilinl  lllr  liHI  \  lllill  filllill, 
idlllllli:  ll>-llilll\    limlrl'  the  iliiliiiliti  III   llli'  (irllli>t.  Ilil\('  IkiII   left   rlllil'i'lv 

lo  iiit)  cart'.  Siill  t'liitlirr.  (Ii«fii>(«  ol'  ihr  car  iirc  im!  >|ii.k.'ii  dt',  r\((|it 
to  Uic  cxlcnl  lliiit  iinsii-|ilijir\  iiirtal  (liM  ii-t  -  iillVci  ihr  hlii^tiiiliiini  tulic. 
Astliiim.  too,  is  (lixiissnl   irmri'  cxlinii.-l  i\r|\    m  wi'll-irrn^'nizi'il  wnrks 

(III  •rcllcral  llli'iiirilK'  tllilll  it  cnllld  lie  within  the  lilllil>  of  tln'M'  |l.'i;.r('>. 
iiml    ciillMilMCIll  ly    llll>    iml     licrll    tlrillid    nl.        Ill    OIK      citlur    poilll     it     l.« 

Ii(»|mmI  tlic  |in)r»'-sii)ii  will  iijircc  willi  llii'  iiiitlmr.  aiiil  tliiit  is  in  tlif 
(VcliiMiiii  (if  ili|ilitlii'riii  rrniii  tlii>  voIiiiih'.  'I'Ih'  iin'iliciil  litcriitiirr  i<\' 
llic  (liiv  i>  lull  of  till'  >ulij((i.  j'',\(  ry  nicdicjil  joi.ritnl  ol'  iiiiy  >liiiiiliiiu 
(llli  tell  till'  liitrsi  with  rciranl  to  this  iliscasr.  Toxins  iiml  iiiitiloxin> 
iiioiii'|inli/c  the  iittciition  ol'  tlir  iiicdiciil  world,  and  yet  tlic  rviict  ^^hihis 
id'  oiir  ami  of  ihr  ollirr  in  rr^anl  to  thr  |iro|)ajrat ion  and  picvriiii.iii 
of  disrasf  it  may  take  another  lialf-(  mt  iiry  to  fiillv  and  ali-ojulcly 
dclitic. 

It  IS  not  thr  authoiV  de-ire  |o  *|ieak  in  any  \\a\  »li^hli!i;^ly  of  the 
iiii|iortaii(e  and  interest  i>\'  lliese  siil«Jee|-,  or  of  the  aii.«o|iite  necessity 
fd'  iiivcsiiiMl  in;;  to  the  ulniost  all  that  «<iei)ce  can  advance  in  nd'eronco 


to  th. 


:'se. 


What 


lie  wishes  lo  sav  i-  that,  after  takiiii:  all  the  cir- 


ciinisl  into  coiisidera  ion,  he  ha.-  acted  ailxiscilly  in  not   idaciiiji 

(liplil'.cna  upon  the  list  of  suhjeets  treated  of. 

Another  reason  for  liiiiitiiiLT  thi<  work  strictly  within  certain  lines 
\\a>  the  de.-ire  to  enter  as  fully  as  s|tiice  would  |icriiiit  into  the  many 
subjects  within  its  ran.iie,  iiiid  to  do  so  in  accordance  with  the  results 
of  the  most  recent  scientific  invosti.iiatioiis.  Iiriii<:in,ir  the  recoril  (d'  the 
art  ami  science  of  laryri^cdojry  and  rliino|o;,fy  down  to  llie  iiiiiiieilinto 


iresent 


Another  ih'partiirc  from  tlie  ordinary  rule  in  works  cd'  this  kind 
has  hcen  luade.  It  is  one,  however,  for  which,  in  the  minds  of  most 
thinkers,  tlie  time  has  arrived.  'I'liis  is  the  snhstitntion  throuuMioiit 
the  work  of  the  metrical  system  of  weights  ami  niea.-iirc.-  for  the  (dd 
Koinan,  which  is  gradually  losing  its  grasp  among  the  civilized  nations 
of  the  world. 

in  one  otlicr  point  luis  lie  straycfl  from  the  idd  and  well-heaten 
way,  and  that  is  by  <>ntirely  leaving  out  the  eniinieration  of  synonyms. 
In  carefully  s(decting  in  eacdi  case  the  title  tliat  lie  deemcHl  most  ap- 
propriate, ho  trusts  that  lio  has  made  a  selection  thiit  will  l>e  sufli- 
ciontly  distinguishing,  and  at  the  same  tiiiu'  fully  aece])tah]o  to  the 


r( 


ador. 


1 


rKKFACK. 


Vll 


In  «nti(lnsion,  tlic  nudior.  with  imuli  <lilli<l,.|ur,  oWrva  his  ooni- 
plmi.'iii.s  to  ihr  pnilV-sioii,  .111,1  lu<  trusts  tlnit.  in  ilicir  criticism  of  his 
work,  tluy  will  ...vlriMl  |„  hi,,,  that  forhcannur  aii.l  kin.liv  i„t,.,-,.st  to 
which  honest  hihoi-.  however  laiiH y.  always  looks  for  its  reward. 


.'17  (  Art!  ION  S,  ,(|.:n,. 

'JOIIONIO.     jlll   IMIIlvK,     IHIHI. 


ACKNOWJ.KlHiMKN'l. 


In  pivpiirinjx  this  work  for  j)ul)liiati()n  the  author  foeU  that  he  in 
iiikUt  (h'«'|t  ohli^'ation  to  vi-ry  many.  Having'  jfathcrod  much  of  liis 
material  from  hooks  aiul  journals'  of  recent  <hitf.  he  extends  to  their 
writers  his  thanks  for  the  valualile  aid  with  whirii  he  lias  thus  l)een 
favoreil.  In  this  he  feels  that  lie  is  })artieularly  indehted  to  Dr.  Jios- 
worth  for  ,i,Mantinj,'  so  freely  tiie  use  of  pictures  and  plates  from  his 
most  recent  work.  To  Mr.  licniio-x  lirowne,  also,  the  author  is  under 
the  highest  oldi^ation,  as  his  kindness  ha.--  eiialiled  him  to  place  ii\  the 
j)resenl  work  a  lonjr  series  (»f  illustrations  taken  throughout  from  i..en- 
nox  lirow  lie's  lifih  edition  unon  "'  ..-.ease  of  Tliroat  and  Xose,"  i.ssued 
so  recently. 

Among  otlier  autliors  whose  writings  he  lins  so  freely  <.'onsulted 
li(>  might  mention  particuhirly  llishop,  ('a.sselherry,  l)ehivan,  l''raenkel, 
(ileitsmann,  (Jrant,  (iriinwald.  ileiyng,  Ingals,  .lonathan  Wriglit, 
Knight,  Kyle,  Lake,  Max  'I'horner,  Myles,  Morell  Mackenzie,  Noland 
Mackenzie,  l{oe,  Sajous,  Semon,  Shurly,  Wagner,  and  Zuckerkandl. 

In  his  own  city  of  Toronto  he  is  umh'r  ohligation  to  Professor 
Primrose  fnr  ihr  serie>  of  frozen  sections  which  he  kindly  permitted 
him  to  ohtain  from  the  Museum  of  the  Anatomical  Department  of  the 
I'niversity  of  Toronto;  and  to  Mr.  Arthur  Bensley,  also  of  the  nni- 
versily,  for  pictures  of  patliological  sections  furnislied  hy  the  author. 

Ife  would  also  acknowledge  his  indehtedncss  to  Jliss  Wrinch  for 
the  care  and  skill  with  which  she  prepared  many  colori>d  and  Tndian- 
ink  illustrations. 

Drs.  Aniyot,  Sweetnam,  Caven,  Carveth,  and  Wilson  also  cordially 
oontrihutcd  a  share  to  the  pathological  work  required. 

To  the  F.  A.  Davis  Co.  the  aiitlmr  owes  much  for  the  unfailing 
promptitude  and  kindness  with  which  he  has  always  heen  treated;  and 
for  the  suggestion^  and  e(>-()]K'ration  which  they  have  ever  heen  willing 
to  grant. 


(viii) 


MKTinCAl-  WKKiins  AM)  MKAM  R|;s 


A\ri  riiK.ijt 


K\(ir,IS|l  IK^nVALKNTS. 


1  ^riiii.iiir  iiiiirkcd  tliii.< I  nuiiil.-    l."..i;i; 

1  tfiiti>;riiMiinc  luarkt'd  tini.s.  .     (il      (t|ii;il«   '   ,,  (,, 

I  millignimiiic  inaikcl  thus..    jOOl  ».(|i!;il,  ,il„Mii 

I  •••■nti^'iaimiio  is  '/,„„  part  of  j.  ^r,j,,nnw. 

1  iiiilli'M-jii 


yiiiins. 


1 


;:rain. 
L'raiii. 


i^M-ainuiu  is  V,o„„  pari   <if  a  ;rrain 
1   litri'  tMnials  ;{:..:>r5.|   fliiidoiinccs. 
1   niftri'  ('(jijals  3!>.;{7!t:!»  inches. 
I   c'lihic  (cntiiMotrc,  marked   1  c. 


inc 


In    d 


li(iuids.  as  weil 


:■.,  cqiiai^    I 
ispcnsin^',    n(>oordin/,'    fo    the    m.ti 


iniiiirib 


a  I 


as  so 


lid.' 


"Vstciii.    ill 


terms  ;:ramn:o,  eeiiti^'rammo,  and  mill 


are  snppo.<ed  to  l.c  wei<;hed.  and  tl 


le 


to  pla 


I'd  faeililale  writin*;  prescrij)ti<)n.s  it 


i^raniiiK   onlv  are  ii- 


decimal  th 


CO  a  perpendicular  line  hetween  Ih 


IS  more  cdnvenient 
c  irramtne  and  tlie 


fract 


ional  part 


m  the  ordinary  plan  of  placin-  a  d..t  t.,  indie:,!,.  (| 


le 


!i 


%. 


fix) 


CONTENTS. 


'I'llI.K      

I)KI)I(  A  IKtN       

I'ltKl'A*  K      

A('K.\()\vi.i;i)(imi;n  I    

AlK'iiK  Ai.  \\i;i(iiirs  AM)  Mkasiuk 

Taiii.!-:  ok  (  (i\ti:\  is 

I.IM    ol     ll.l  I  sriiA  IIONS 


TACK 

i 

iii 

\' 

viii 

i.v 

X 

.     xvii 


si:(  'iioN 


DISKASKS  OK    IllK  NASAL   l'ASSA( .  KS, 


('iiai'Ii;k    I.     A.NAioMv    ()(■     iiii:    Mxikknai.    Nusi:,    Nasai     I'assauks, 

AM)    AccKSSOUY     SlMsKS 

Exloriiiil  iinsc.  :i:  iiiisiil  I'lissic.  .'i :  frontal  sinus,  (i;  s|ili(>iiiii(l.  7: 
t'llliniiitl  cells.  7;  iiiaxilliUX'  sinus.  S ;  ncrxcs.  11:  liluod  vessels. 
11;    f,'lan(ls.    11. 

CllAl'TKlt    II.       i'llVSIOI.()(a     Ol      1111,    .NdsK    AM)    .\( CKSSOKV    Sl.MSK.S 

Sense  of  smell.  I'J:  llii'  nose  in  plioi  ation.  I'J:  the  nose  in  respira- 
tion. i:i. 

(  iiAiTKi!  III.  — Instiu  mi:n  rs  Iskd  loit   iiii-;  F.xamina  iion  and   TiiKM 

Mi:\T   OK    DtSKASKS  OK  TIIK   Nosi;    AM)  'I'mioAr 

I'",leetrie  lani|i.  1."):  lieadiuiirois.  1(1:  .Mackenzie  eoni-cntiator.  17: 
nasal  s]ieculum.  17:  Kosw  ortli'-.  IS:  Slmrly's.  IS;  ( loodw  illie's, 
IS;  Myles"s.  IS:  Sincrock"s.  IS;  jiost  rliinal  mirror.  I'.l;  self- 
retaininir  jialali' retriictor.  1!':  roiioii  a|i|iliciitors.  2(1;  tonjiue- 
(le])ressoi"s  'Jl  :  atomi/e|s.  -Ji' :  insullialor-i.  'I'.l:  jiost-nasal 
syriiifjfcs.  2.'!;  coin|ire<>c(l  air  apparatiw.  'J.'i :  uasiil  ^aws,  21; 
<'liisels,  2");  iliills.  2(');  cold  w  ire  snares.  2(i:  j.m1\  aiiocaufery 
siiiires,  27:  spokcsliaves.  2S ;  |iunclies.  2S:  curelles,  curved 
sci-sois.  nasal  hiiri*.  etc..  2S ;    antciior  rliinoscn|iy.  2!!;    ))osteri(>r 

lliilloseo|iy.    ;!(t. 

l)isKAsi:s  Ol-    IIII'   NdsK. 

ClIAl-lKl!     I\'.       .VciTK     IJlllMTlS 

I'alliolofry.  ■i'2:  cliolo^iN.  .{2;  syin|ptoniiilolo>,'y.  .",2:  dia^ruosis.  '.V.\: 
|)roji;nosis.  ;!;! :     |)ro|iliyla\is.   ;{,'! :     treatment.  .'!t. 

ClIAlTKIt    \'.      ClIliONK      HlIIMIlS 

I'atliolofT.v.  ;i7  :  etiolojiy,  ;f7  ;  syiu|)tomatoloi.'y.  .'(7;  diafrnosis.  3S ; 
)irojj;iiosis.  ;{S;    treatment.  .'^S. 

(   IIAI-IKU    \l.       I'lItCI.KNl     KlllNiriS    OK    (   11 1 1.DliKN     

I'atlioliifjy.  41;  etiolofry.  42;  symptomatoloe-y.  12;  diajruosis,  42: 
[iroefnosis.  (ili:    treatment.  43. 

(  uvri  Kii  \'II.     II  vi'Kitritoriiic  KiiiM  ris 

I'at  lioloify.  4,"):  etiolofjy.  47;  syni|itomatol()f>y.  4!t;  dii\;rnosis.  ")(); 
profrnosis.  ft\ :  treatment.  51;  ojieration  by  eliromic  acid.  52; 
i>|)eralion  liy  fralMinoeaiitery-knife,  52:  ^'alvanoeaulerv  snare, 
51:  operation  l)y  electrolysis.  55;  turhineetoiny.  5(i:  olectro- 
eauterv  ]iiinctiire.  57;    snhmucous  knife  incision.  57. 

(X) 


12 


32 


37 


41 


45 


(ON  I  lA  IS. 


M 


12 


i:> 


.^2 


37 


n 


»,") 


t'HAPTEK     VIII        ATUOI'HK      KlIIMTIS 

l*ath(>liij,'y,  r»H:  t'tiiiloj,'.v,  riil;  syinptiniialolu;,'^  till;  (liii;:iiii>i->.  (il  ; 
luujriiuMs,  »i2:  trratnu'iit.  tl2:  use  <if  the  pont  nasal  syriii}."'.  (i.l; 
(;(>lt>tfiirs  |(lii;is,  t;J:    tn-almt'iit  h\   u\A<-i;{<:i\  M. 

CllArTKIl    l\.       (KdIMAKH  S    l!lll.MTI^*. 


I'A(.K. 

."iS 


t'llAl'TKH     X.       I'lUUINDl  s     KlIlM  I  l> 

Ndii  ili|ilitliriiiic.   T'l:     tiaiiitialic   iiifiiiliiiiinni-.    iliiiiii  i-;.    72:     t|ii(-< 
'lion  III'  iili'iility  of  liliriiioiis  i'liiniti-<  with  ili|>litlii  ria.  Tii. 

(.HAiTii!  XI.     l)i:i  oKMiriKs  ()!•    iiii':   N'asai.  Ski- mm 

I'lcxaltiiic  of  -ciital  (Icfni  nlilit■•^  anmn;:  rivili/id  ra<i'-..  74:  rarity 
III  ili'forinitirs  aniini;:  almii^nnal  rarcs,  '■\;  cxaniiiiat  inn  nf  Indian 
skulls.  74:  cla-^ilicalion  of  (lc\  iat  inns.  ;.'i:  t'tiolniry.  7.");  views 
of  /iirkcrkantll.  l!o<'.  'ricndficiilinrir.  .Mayo  ColliiT.  upon  laiisa- 
tion,  7ii;  >y  niptoinatolo^'y,  SI:  (lia^'no>is.  SI;  |.!otrno>is,  S2 ; 
Irciilincnl.  s-J :  liy  us*-  of  saws,  s;{ :  knixt's.  S;{;  liuns.  s;i ; 
ln;;al>'s  incllioil.  S;i ;  LoolTs  indlioil.  s;{ :  liy  i  lc<)rolysis.  S4  :  liy 
n-c  of  sihcr  tnla's,  H't;  liy  Watson's  nictliod.  St!;  hy  usi-  of 
inliltcr  splints.  SS. 

CiiArri'.u  Ml.     DisToimoN  oi    riii:  Coii  mnak  (aim  ii  ai.i: 

CiiArir.n  XIII.     I'i:iti  iiitATiiiN  oi-   nii:  Scrii  m    

Kliolo>:y.  Ill  :  tifatnicnt.  ill.  .Mis.c-^  of  the  M'plnni.  !I2.  I'lci  ra- 
tion of  tlic  septum.  '.12. 


•  >7 
70 


CiiAi'TKU  Xl\.     II. XV   l"i:\  i:ii.  (lit  \  .<  sdNKmiu  ItniMiis 

I'at  lioloj.ry.  li.'t:  ctioldi.'y.  !I4;  alinonnally  sennit  i\i'  nci\  i' rcni  ii'^. 
!I4;  liy|i('iii'>tlu"»ia  of  tlic  pt'iiplirral  tciniini.  '.14:  |irt's»uri'  of  an 
irrita*  injr  aircnl . '.i.'i:  tlic  polirn  IIh'oi'v,  H.");  llic  uric  acitl  theory, 
!lti:  syniptonia1olo<ry.  !itl;  diaf.'nosi-i,  !IS:  |iriiirnosis.  !IS;  juc- 
vcntivc  mca-iiic<.  '.IS;  .natnicnt.  ii'.l;  constitutional  ticatincnt. 
!lil;  t  i<'at  niciit  of  the  di^ea^cd  condition  of  the  na-al  passiiy;es. 
1(111;  treatment  of  the  spa-niodic  .iltack.  Itid.  Na-al  hvdior 
rh.ea.   lii:!. 

<  iiAi"ii:i!    X\'.      .\N(ismi.\:     r.MiosMiA:      I'l  in  \(  i  i.osis 

.\nosniia.   liM:     paio>inia.   1(15;    fnnini  ulosi-..   Id,"). 

CiiAi'i  iii  X\l.     I'.nsi  .WIS    

I'atholo<,'y,  1(1(1;  etioloi.'y.  l(l(i:  syniploiiial(Ooi;y.  HKi;  diai:iio--is, 
107:     jiroijiiosis.    |II7:     treatment.    Iti7. 

C'lIAI'Ill!    X\II.      li'lllNninils:      I'ditl.It.N    r.oliIIS:      I '  \I!.\Si  1  i:s 

IJIiiiioliths.  llii;  >ym|itomatoloi_ry.  IK):  diaj.'nosis.  111;  prot;no>is, 
111;  treatment.  111.  l'orei;;n  liodie-.  1  12;  syniptoinatoloiry.  ||2: 
dia;.'-|i"sis,  112:  treatment.  II.'!.  .trasiics.  li:t;  Miiscii  innii- 
tiiiiii.  riiiniisiiiiniiii  iinifti  Ihirin.  Ill:  symptomatology.  111: 
I  reatment ,    1 1,'). 

CiiM'iKii    Will.     Nasai,    I'm  vim 

I'alholo^'y.  11(1:  site  of  attaelimeiil .  117:  eiinloMy.  IIS;  v\m|ii(im 
atolooy.  1111;  dia;,'iiosi<.  pJl;  proe;Mo-i<,  121;  treatment.  122; 
li.\    snares.   l-_'2;     liy  the  use  of  foicep-.    i2."i:     liy   clectroh  si<.    |_'."(. 

('HAi'lllt    XIN.       r.\l'Il.l()M.\     


Sit 

',11 
'.i;! 


1()» 


Hill 


I'atholojL'V.   12(1;     treatment.    127.     Ililateral   tumors  of  tli 


l.xMiphoid    \: 


■rci't  1 


\ariei\.    1: 


'pi  iim. 
treatment , 


CllAI'lKIt     .\X.       I'lltlidMA 


I'atholoe-y,    12S:    eliolocry,    IJS;     syinptomatolojry.    12S:     dia>riiosi 
I2!l:    piojriiosis.  12!».;    treatment.  I2!l.     History  of  a  case,  Kid. 


12S 


xn 


CONTKNTS. 


PAOE 
ClIAI'TKK    XXI.       ADKNOMA:       AsiiHiMA KVi 

Adciioniii,  l.'12;    an^rinniii.  I.'t.'j. 

ClIAI'TKK   XXn.    -CY^ST()MA   Ol     Till-:    NosK 134 

ClIAl'TKU    XXIII.      ('MO.N'DIiOMA  :      ( )sTi;().\l  A 130 

C'lioiidroiiia.  \'Mi.  (Islcnina,  l.'{(»;  patliolciifv.  l.'JT:  cliolngy,  l-'?7: 
Kyiii|il()inat<)I()}fy,  l,')";    f rcatniciil,  ]'M. 

ClIAI'TKK     X.\l\'.       SaU(  .>.MA     13» 

l'atli<il(ijry.  l.'tS:  of idlofry.  |:iS:  -y iiiptiiiiiiitul(i;ry.  |;{!i;  diagiioHi'^, 
l;f!l;     |Hii<,nio«is,   l.'5'.t:     treat  rnciit ,    l.'C.t 

ClIAI'TKK    X.W.      (AKriNOMA     141 

I'atlidldfry,  141;  clidliifry.  141;  s\  iii|it(iiiiiiliil(iffy.  141;  ilia^iiU'^is, 
I4"2;    ]iro;;n()sis,  142;    Ircatiiiciil .   \  i'2. 

Chai'tkk   XW'I.     'rniKKcri.osis    143 

Talliolo^ry,  143;  cliold^iy,  144;  sympt(Hiiati>!o;.'v.  144:  diaj^iiosis, 
144;    profjiiosis,  144;    Iroatinciit.  14"). 

ClIAI'TKK    XXVII.       1,1  IT.'^;     (Jl.ANDKKS 14(> 

l,ll|ilis,  14ti:  iialliolofty,  I4('>;  ct  inl(i!,'y.  14ti:  sy  ni])lomati)lny;y, 
14tl;  (liajfiiiisis,  147;  prognosi's.  147;  trratinciit.  147.  ( ihindcrs, 
I4S. 

ClIAPTEK    XX\I!I.  -    l{lllNOS(I.KKOMA     149 

CiiAPTKK   XXIN.     SYriiii.i.><    151 

Muc()\H  patch.  I.'il ;  siipt'i'lk'ial  iik-cr,  ir>I ;  bony  iiporosis,  ir)l  ; 
patli(>liiy:y,  ir)2;  symptoiiiatolofry.  \'>'l:  diafriKPsis,  153;  proj^ 
iKisis,   153;     trt'atiiicnt,   153. 

ClIAI'TKK     XXX.      roNCKMTAI.     SY1'IIII.I.>< 155 

Sviiipt<)inatol()fj;v.  155;    diagnosis,  155;    i)ro<;iio«is.  |.")(i:    tifalinoiit. 
■l5(;. 

DiSKASKS   OK   ACCESSOKY    Sl.MSKS   Ol     TilK    No.SK. 
CHAI'TKK     XXXI.       ACITK    SlMSITIS     1  i")9 

Ktiolofry.  I5!»;    syinptoniatolofiy,  Kid;    tnatnicnt.  Mil. 

ClIAI'TKK    XXXIl.       ClIKOMC    DiSKASK  OK   TIIK    AXTKIM    OK    Ill<  IIMOKK  lti2 

Patliolofjy,  Itlli;  ctiolofry.  I(i5;  syiuptoniatolopy.  lt»5;  diafiiiosis. 
1(1(1;  pidjriiosis,  l(i!);  trcatinciit.  Id!);  first,  by  direct  irrijiiitimi 
thioii>rli  the  ostiimi.  1(!!»;  second,  by  o|ipiiin(j  (hroiiffh  (ho  in- 
ferior meatus.  Kilt;  tliiid,  by  removini;  a  tooth  and  washing 
tliiongh  (he  alve(dus.  170;  fourth,  by  opening  (ho  canine  fossa, 
170;  tiftli,  bv  the  condiined  method.  171.  ('\st  of  (he  antrum, 
174.  ■ 

CllAI'TKI!    XXXIII.      IvrilMOll)    DiSKASE 175 

I'adiology,    175;     eliology.    17(i;     syuiploniatology.    177;     diagnosis, 
77:    ]>rognosis.  177;    (rendiient,  17!^. 

ClIAI'TEK    XXXIV.     Sl'IlK.NOin    DISKASK 180 

Frontal-sinns  disease.   IS  I. 

SKCTION    II.     DISKASKS  OK   rilK   I'llAKVNX. 

ClIAI'TKK    XXXV.       .\NATOMY    OK    TIIK    PlIAKYNX 185 

Houndaries,  1H5;  openings  in(o  (ho  jiharynx.  IS5;  mucous  mom- 
hraiio,  IH!);  jdiaryngeal  glands,  l!t(l;  arteries.  IJtfl;  veins,  100; 
nerves,  1!(0;  naso  pharynv,  l!tO;  faucial  tonsils,  101;  lingii.nl 
tonsils,  101. 


^ 


Itl 


coNrKNTs.  xi'i 

l»AOE 

('IIA|-Ii:it    XXWl         PllYSl()l.()(iY    Ol     TUK    I'lIAItYNX Ut.'J 

Division  into  niiso pharynx  and  oropharynx.  1!>.'{;  the  soft  pahito, 
Mt.'i;  lissnos  of  (he  oro-pliarynx.  1!)3;  (h'fjlutit ion.  1!>3:  physio- 
h)^nral  fnnctioim  of  the  tfinsils,   H14. 

DlSKASKS   OK    Tin:    \AS0  I'HAHYNX, 

ClIAI'TKK     WWII.      NaSO  lMIAUYN<ii:AI.    (AiAnnii 1!>5 

Pathology,  lO'i:  otiolofjv.  |!MI;  syni|iloni:ilnlofr\ .  ijiS;  diaHiui.sis, 
l!t!t;     I'lroffnosis,   1<I!»;    "trcatnionl".   !!•!•. 

Cmai'tkk  .X.X.W'in.     .\i)i:.\()ii)  (liiowi  lis  Ol    riii;  Naso  i-iiakynx 204 

l'atIioloj,ry.  •2(M:  ctiolofry.  2<M!:  syinptoin.itohifry,  'H*7 :  ^rcnorai 
symptoms,  2(IS;  cxtfrnal  (icftirmitics  of  nose  and  chest  due  to 
tiie  disease,  20!):  dia},'nosis.  lild;  proffiKisis,  210;  treatment,  211  ; 
{reiicral  ana'sthesia  durint.'  operative  treatment  advisat  le  witli 
ehildren,  212;  relative  merits  of  ether,  bromide,  of  ethyl,  nitrous 
oxi(h'.  and  ehloroform.  21.'i:  operations  by  galvanoeau'tt'ry,  214; 
snares,  214;    i)ost-iiharynpeaI  forceps.  214;    curettes.  215.' 

CiiAiTKu  XXXIX.-   MYXoiinno.\fA  of  tuf.  .Naso  imiary.nx 217 

I'atholopy,  217;  etiolofry,  218;  symptomatolofry.  218;  diaf,'nosis, 
21!»;    prognosis,  2 lit;    treatment ,' 2I!t;    report  of  cases.  220,  221. 

C'JiAi'TEU  XL.     Fiukoma  ok  nn;  \as'>  i'hauynx 223 

Patholon-y,  22.3;  etiology.  223;  symptomatology.  224:  diagnosis, 
224;    prognosis,  224:    treatindit,  224. 

CiiAi'TEU  XI.I.-Mai.ki.nant  Diskasks  (11    Tin:  .Va.so  i-iiauynx 227 

Sarcoma,  227;  jiathology.  227;  etiology.  227;  syinptomatologv, 
227;  diagnosis.  227:  prognosis,  228;'  treatment,  228.  Carci- 
noma. 220.  (  hondroniii  of  tho  nasopharynx,  2.30.  Foreign 
bodies.  2.30. 

l)isi:ASi:s  OK  TiiK  Oho  riiAHYNX. 

CHAI'TKK   XIJI.      .\(  ITI-   rilAIlYXOITIS 231 

rathr)logy.  231;  etiology,  231;  symptomatology,  2.32;  (iiagno.sis, 
233:  jirognosis.  2.33;  treatment".  233:  comparison  of  the  values 
of  eoeaine  and  eueaine.  233. 

CiiAPTKif    XI, III.     CiiHoxic   riiAinX(;iTis 237 

Pathology.  237:  etiology,  237:  symptomatologv.  2.3.S :  diairnosis, 
238;    prognosis,  238;    treatment!  23!t. 

TiiAi'TKi!  XI. I\'.     ToMK  iT.Ai!   I'll  A  H  Y  .\(irns 240 

Pathology.  240;  etiology,  240;  symptomatologv.  241:  diagnosis, 
242;    prognosis.  243:    treatment,  243. 

CiiAi'TKit  XLV.     .VciTi:  'roNsii.i.rn.s.  or  (^iinsv    24.5 

Pjithology.  24;");  site  of  abscess.  24t!:  etiology.  247:  svmittom- 
atology,  247:  di.ignosis.  248;  prognosis.  24!'t;  treatment.  240. 
(Question  of  the  time  the  abscess  should  be  incised.  2.')0. 

Chapter  XLVI.— Diseases  ok  the  Cvi  i  a;    (Kdema;    Ki.onoation.  252 

(Kdema.  252;  etiology.  2.V2:  symptomatologv.  2.")2 ;  jirognosis,  252; 
treatment.  2.52.  Klongatinn"  of  (he  uvula."  253;  patholngv,'  253; 
e(iology.  253;  symptomatology.  2,")4 :  diagnosis.  2.54;  prognosis', 
254:    treatment,  255. 

Chatter  XL\'ir.-  Rethopiiaryxoeai,  Ans(  kss 258 

Pathology.  258;  etiology,  2.58;  symptomatologv,  2.50:  diagnosis, 
2.50:    prognosis,  200;    treatment".  200. 


1 


XIV 


(II  A  I 


ClIAl 


(11 A I 


(11  A  I 


(11 A I 


(HA  I 


ClIAl 


(  IIAl 


ClIAl 


C'lAI 


ClIAl 


ClIAl 


CONTKNTS. 

PA  (IE 

IKK  XI.Nlll.     lIvrKiM  lioi'iiv  ()!■  nil-:  FAitiAi    Tonsils •2(i2 

l'iillit>lnj,'y.  2(i2:     ct  ioliifry,  2(14;     syiii|it4iiiial<>l«i;x\ .  2(i4  :     (liiif;iiii.-iiH, 
'M't'y.     ]niij;m>sis.   2(l(i;     t  icat  miciiI.   liliT :     iiit'dical.   2(17:     ^ur^'iciil, 
2(17;      toiisillotoiiiy.    2ti7 :      sccniiilarv    liii'imii  rlia;.'i'    at'tcr    tonsil 
lotoiiiy,  2(>!l;     (>|i<'i'ati()ii    liv   colilw  ire  snare.  27(1;     sci.-sors.  270; 
caiitciy,  271. 

TKK  XLIX. —  LAtlNAll  'r<).\sii.i.iTis 272 

l'atlii)l<)<.jy,  272;  t'Molofry,  27:i:  syni|>t()iiiati>|iiu:y.  27;{:  (lia>;iir.,is, 
274;    ]ir<i<,'n()sis.  27r>;    IrcatiiH'iit,  27'). 

ii:ij  L.     I'liAUVNCiKAi,  .My( osis 277 

J'afli;>l<)<ry,  277;  cliolopy,  27!l;  syni|)t()nia((il<ifr\ .  2S|;  iliaiiiici^is, 
2S2;     proffiiosift.  2H2;    trcatincnt.  2.S2. 

TI  1!   1,1.      Ihl'I'IlTlirHMlY  (H-  Till-;   r.I.NMil  Al    ToNsii 2S4 

I'atlinjdf.'y,  21S4.  <'|i()lnfry.  2sr);  syinptoiiialolnfiy.  2S(!:  diaf^iiosis, 
2S7;  ]iri)<rn()sis,  2S7 ;  licatiiK'nt .  2S7 :  i)|i('raMi)n  l)y  <.'nlvani>- 
cault'ry,  2S8;  by  liii<;nal  tonsillotonic.  2HS:  1)\-  hot  or  fold  siiaio. 
288. 

TKU    lAl. —  HK.NKiN     Tr.MOHS    Ol'    TIIK    IMlAUYNX 2!H) 

l*a|>iIloiiia.  2!M1;  iiliroiiia.  2!t():  oju'iativc  (rcalniciit.  2!il.  .Vdcnoiua, 
2!)l.     Dermoid  Imiiors.  2!t2. 

•ii:k  I,1II.--Ti  iii;i{<  ri.osis  oi-    riiK  I'iiauv.nx 293 

I'alliolo<,'y,  2!t;{;  etiolo{;y,  2!>.'{;  syin|i1oinalolo<,'y.  2!14:  (lia<;iiosis, 
2!t4;     profTiiosis,  2itr);     treatment,  2!tr». 

TICK  1,1V.     l.iiMs  or  Tin:  I'iiaiiynx 297 

Patliolojry,  2!I7:  et  ioloiry.  2!IS ;  syinplomatolojry.  2!t8 ;  diaj^nosis, 
2!>!>:     ilrof;>-osis.  :{(l(»:    'treat  iiiciit'.  :{(»(). 

1  Kit  l,V.     Syimums  ok  nil':   I'hauynx .'?0I 

I'atliolojfy.  .'{(tl  ;  primary,  secondary,  and  tertiary  lesions.  :!()l:  e(i- 
olo<ry.  .'(02;  symptomalolojjy.  .■{(12;  diajjnosis.  ;{()4:  elianerc. 
sy|)liilitie  erytlii'ina.  miie<ins  ]iateli,  j:\ininiy  tuinois.  deep  ulcers. 
I'ieatrieial  tissues,  ;{((4.  .'id.');  prof^nosis.  ."ill.");  Ireatnicnt.  'M)■^. 
.Xctinomycosis.  30(i, 

TKI!    I,\l.       SaI!<  OMA   OI     lUV.   Ka  ICK.s .'{07 

I'atlioloNy.  .■!()7:    et  iolojr.v.   .■!(t7:     syniptoinaf  oloir.v.   oOS;     diajfnosi-. 

;)(I8;    jirojriiosis.  .'td'.l:    t  reat  nK'iit'.  :i(Mt.     Leukoplakia  palali.  .TKi. 

ri;i!  l,\ll.     Caiscinoma  oi'   riii-;  I'.mcks :?11 

I'atlioli'jiy.   :{|1:     etiolo|.'y.   I!l.'t:     -.ymploiuatidoLry.   .'!l,'{;     diagnosis. 

.'il4;    ]iro<,'iiosis.  :il.'i:    ticatmeiit.  :{|.i. 

nii   l,\'lll.     Ni:riiosi:s  ok    riiK   Kaicks 318 

Nciirose-i  of  sensation.  .'ilS;  liypcra'stlicsia.  jiara'stlifl-iia.  ;ilS: 
neuralfjia.  ,'ilS.  Nenrosc-i  of  motion.  ;jl!t:  spasm  of  tlio  ]iliaryn\. 
,'!l!):  paralysis  of  the  ]iharvnx.  31!);  myopathic  jiaralysis.  31!t: 
]ialato  <rliisso  ])har\ii<rcal  paralvsis.  ,321);  acute  hnlhar  paralysis. 
.•i2(». 

TKU  I.IX.     'roNsii.i  rnis.     l"oi!Ki<i\  Hodiks  in    i  iik  Faicks .321 

Tonsillitlis.  321.  Foreijfii  iMidies.  322;  svniptoms.  322;  ]>rof5nosis. 
323:     treatment.  323. 


I 


SK(  T|()\  111.     I)|SK.\SKS  OK  riiK  i,.\i;ynx. 

ClIAl      .'{  1,X.     .Anatomy  ok  tiik  Fakynx 327 

Anatomy  of  the  eiieoid.  327;  the  thyroid,  328;  the  arvtonoids, 
320;  the  epifrloUis.  3,30;  the  lifrinnents.  331:  (he  articulations. 
3,34;  the  muscles.  3,3.');  (ho  arteries.  .33,");  the  lyuipludics.  33'); 
the  ni'rve-i.  ;i3,") :     (he  mucoui  mcmhranc.  ,3.3,">. 


(()Nri:M>.  XV 

r.xf.i: 

ClIAriKK    LXI.       I'lIVSlOl.iX.Y    OK   TllK    I-AKY     X .'!.'17 

iMHictioiis  of  llio  liirvnx.  .'f.'!7 :  ic«i|iiratiiiii.  ;i;!7 ;  )iliiiiial  inn.  ;f:fS; 
pitch,  :VM:     intensity.  :i:i!i:    ciu:ility,  :!.{!•. 

C'iiAiTKii  LXIF.     LAUV\(ios( oi-v   ;j4it 

The  use  of  tlic  tliroat-niinor.  :{KI;  t'xainiiiation  of  tin-  laryn\.  .'ftii; 
lioldinfif  the  tonf^iH",  ;{4<i;  view  of  the  v  >i'al  conls.  :\\2:  po^ilioii 
of  the  ('[liirlottis.  :iA2:  piclnrc  of  tiic  larynx.  .'U:!:  po-iiion  of  pa- 
tient in  laryiif;oiiiffieal  examination.  ."{44. 

<'iiAi>Ti:u    lAili.     AfKiscoi'Y    :il.') 

Chai'iku    I.XIW     Inti  iiation    :!.")(• 

<   IIAl'IKK    lAV. — 'JllA(  111:0  If)MY:     TllYKoroMY ;!.")! 

Instruments  re(|uire(l.  ;i.")4:  iliseases  for  wliieh  tlic  operation  may 
l)f'  re(|uireil.  .'{.")4:  nci'essity  for  anii'stlii"»ia.  ;!.").">;  eiioice  of  allies- 
tlK'tics.  ;!.").■);  tlie  use  iif  eoeaiiie.  'iM;  the  hiirh  op<'iation.  :!.")7 : 
tlie  low  operation.  .'!.")S ;    thyrotomy,  .'!.")S. 

(  llAl'TKI!     I.XVf."  ACI  TK     l,AltYX(UTIS I'.CrJ 

I'atholoMfv.  ;{()2:  etiolo}.'y.  'M'fl:  symptomatohi;;y,  :!();{;  diagnosis. 
."Ui.'J;    ])ro<rnosis.  ;itl4;     treatment.  :{ti4. 

C'liArTi'.u   LX\II.     .\(  1  11;   r.AltY\<HTIS  oi'  ('iiii.i>1!i:n :!(i7 

l'atliohi<,'y.  ;i(i7;  etiolojr.v.  •i<i7 :  symptomatolo;;y.  :>liS:  liiaj^iiosis, 
.'{(iS:    I'lrojrnosis.  .'!()!»:    "treatment",  .'iti'.t. 

<'iiAi'Ti;i{   i.XVIII. — .\(  iTK  (Kdkmatois   Lahymutis .{71 

I'atliolofry.  1^71;  etiolojry.  .'i7l;  symptoma1ol(ij;y.  :','-2;  cliaj;iiosis, 
'M'2:    ]ir(i^nosis.  .'i7."{:     treatment,  .■{7."i. 

f'llAlTEU    I, NIX.      ."^IMlM.l.   (Kni.MA    OI-     Till'.    l.AHY.NN ^^7't 

I'atliolo^'y,  .'?7"):  etiohijry.  •■!7"):  symptoniatoloMy.  .'!7">:  <Iiagno-i<, 
.'i7(>;     jirojfiiosis.   ,'i7(l:     tieatnieiil .   .■!7t>. 

CiiAiTKi!  lA'X.-    (  iiitoMc  LAiiYNciiris ;!77 

l'allioh]<ry.  .■J77:  etiolofry.  .^77:  syniptomato]ci<ry.  "S ;  (lia;jno-i-. 
:i7');    ]iidijrn(isis.  ;{7!t :    treatment,  HSd. 

CiiAi'TKi!  I.XXi.    -AritoiMiic  LAHY\(;n  i.-< :!s4 

J'atliohifry,  .'?S4  :  svmptomatolojfv,  .'>S4 ;  iliaj;nosis,  ;i,s."> ;  jiro^fiio-is. 
.^S-);    treatment.'  38,"). 

CiiAiTri!  lA'Xir.     l'A(iiYi)i:nMiA  I,auyn(;is :!S7 

I'atholooy.  .'!S7:  etiolojry.  .'t.S7 :  symi>toinalolofry.  3,SS:  (]ia;.'nosis. 
."iS.S:  pi«i<rnosis.  :i,SS:  treadnenl.  .^S!!:  |iaeliy(h'rmia  consiripta. 
.3.S!l:    pachx  cleniiiii    (iilliisa.    :!S<l.      Sul'jrloHie   cliroiiic    hirvni'itis 

C'liAi'TEi!  I.XaIII.     l'si:ri)()\ir.Mi!i!ANors  I,auyn<.ii!s :!iii 

CiiAi-rr-H   i.XXi\'.     I.AiiYNcKAi.  l'i;i!iriio\i)itiTis ;{!».! 

]*atiio|.j<ry,  :{!i;!;  etiolojry.  .'5!l.T;  symptomatoloiry.  :{<);{:  (lia;.'no-is, 
.1!t4;  hi-tory  of  a  ease.  .W."i ;  'pro^rnosis.  ,n;t,")':  treatmenr.  .T.tli. 
AU'eetimis  of  (lie  erieoarytenoid  artieiilal  ion,  .'100. 

f'liAi'TKij  I.XXV.      Ti  lir.ucii.o.sis  or  thk  I.ai:-^  \\ 3!is 

I'atliohifry,  :!nS:  etiolonry,  ;{!i!l ;  syinptomaloloj,ry,  :<!»!»:  dia^rnusis. 
40(1;  pri'i.Miosi<.  401:  (reatment.  4(t-2:  intrahuynr;eal  siirj,'ienl 
treatnieiil,  4(».'i:  eiind tement..  4(U:  eonda-indicat ion«  of  cmetle- 
inont.  403:    traclieotomy  and  larynfrotomy.  40:!. 

i'li.M'iru  LXX\r.-  T.TIMS  or  tiik  T^auynx 401; 

I'atliolofry  and  otinhicry.  4()(;:  symplom.ttcdojry.  407:  diaiinosi*. 
407:    prognosis,  408;     treatment.  40S. 


XVI 


CONTENTS. 


CiiAPTKK  LXXVIf.—  I.ki'Hosy  oi    tiik  Aiu  i'AssA(ii;s 410 

Leprosy  of  tlie  nose.  411.  Leprosy  of  the  mouth  and  pharynx.  41;?. 
Leprosy  of  the  laryn.x,  412;    treatment,  414. 

CiiAi'TKK  LXXVIIL—  Syimiii.is  oi    thk  Lary.nx 415 

Palholofjy.  41");  etiolojjy.  41(1;  syni|)lomatiilo<ry.  417;  diaj^nosi^, 
417;  prof^nosis,  418;  treatment,  418;  snrf^ical  (icatinent,  41S. 
('on<(eni(al  sypliilis  of  the  laryn.x,  420. 

Cjiai'TEU  LX.XIX.-    .\i:ri{()si;.s  ok  riiK  Lauynx 421 

Nenro.ses  of  sensation.  421.  Anu'stliesia,  liypenesthesia.  para's- 
thesia,  iieural<:ii,  421;  treatment,  421.  Nervnus  aplionia,  422; 
sympt.oni:itol(i<ry.  422;  treatment.  422.  Neuro>es  of  motion,  42.S. 
Spasm  of  the  ghjttis,  42H ;  i'liolofjrv,  423;  symplomatolofry,  42.'V; 
(liatrnosis,  424;  prognosis.  424;  treatment.  425.  I'aralysis  of  the 
laryn.x,  420.  Alidiutor  par;ilysis.  42t).  Hilateral  |iaraly«is,  427; 
treatment,  428. 

ClIAl'TKK    LXXX. — XO.NMAI.ICNANT    TlMOHS    OI-     1  HE    LaUYNX 429 

I'aftilloma,  429;    fibroma.  429;     cystoma.   430;     lipoma,   4;>it;     an 
gionia.  430;     sym])tomatology,  430;     diagnosis.  431;     prognosis, 
432;    treatment.  432.     Knehondroma,  433;    midtiple  papillomata 
of  children,  434;    treatment  by  trucheotomy,  434. 

CiiAi'TEU  T>XXX[. — Mai Ki.NANT  Tr.Mo»8  ok  the  Larynx 436 

J'athology,  437;  symptomatology,  437;  diagnosis.  438;  jirognosis, 
438;  treatment,  438;  endolaryngeal  ojK'ration,  439;  hnyngec- 
tomy  by  Solis-Cohcn  o|K-rntion,  440;  l)ehivan"s  rules  for  gniil- 
ance,  440;    Middiemas  Hunt's  case,  441. 

Ciiai  TER  LXXXIL — Foreign  Hodies  in  the  Laisynx 442 

Svmplomatologv,  443;    diagnosis.  443 ;    pi'ogno>is,  444;    treatment. 
■  445. 

Chapter  LXXXIIL-  Hoentoen  Kays  in  Larynoeai,  Sltroeuy 447 

Chapter  LXXXIV.- Operations  for  Nasai,  Deformities 449 

Annandale's  operation.  450;  Ellet's  operation,  450;  Roe's  subcuta- 
neous operations,  451. 

Chapter  IAXXV.  -(H'krations  for  Ci.eft  Palate 454 

Stapliylorrhaphy.  455;  MacDonald's  opc'ration.  455.  rrano])la8ty, 
450;  Ferguson's  opei-ation,  450;  Mason  Warren's  method,  450; 
lirophy's  mctiiod.  457;  before  operation.  457;  operation,  458; 
aft«r  oj)oration.  45S:    Owen^'s  opinion.  459. 

Index  to  Literary  Kei  krinc  ks 461 

General  Index    464 


I-IST  OF   IIJ.rSTKATlONS. 


11(1. 
I. 


s. 

it. 
Id, 
II. 
12. 
13. 
14. 
15. 
Hi. 
17. 
IS. 
IS). 
20. 
21. 
22. 
23! 
24. 
25. 
2fi. 
2fiff. 
27. 
28. 
28«. 
28h. 
28r. 
29. 

.•to. 

31. 
32. 
33. 
34. 
35. 
3(). 
37. 
38. 
39. 
40. 
41. 


Ciirtiliifjci  of  tlu'  iiosc  xM'ii  ill  |iri)lili' 

Sagittal  section  of  skull,   just   lo  the  ri;,'lit  of  the  septum,  show  int; 

ii;,'lit  nasal  fossa ^ 

Anterior  section   of  the  nostrils 

The   ]>osterior   rhiiiosco|iie    iiiia<;e 

Frozen  section  of  head  of  adult   1  color  <-ut ) 

IMiillips's  <>Iectric  |ihoto|ilii.ne,  willi  adjusliiiciil    for  focusin<{  light.. 

Head  iiiiiro.r '. 

ll(  ad-mirror   in    posit  ion 

Laryngoscope,  gas  stand,  mirror,  condenser.  ;iiid  liihiiig 

liosworlli's   hirge   and   small    nasal   <<|(ecnla 

<!o<i(lu  illie's    nasal    speculum 

M ylcs's    nasal    speculum 

Sincroek's    nasal   s])eculuni 

Sincrock's  nasal  speculum,  with  handle 

l^usworth's  nasal  speculum,  with  sjiicld  for  (autcry work 

Shurly's    nasal    speculum ' 

Post-rhimil   mirror 

Post-rhinal   mirror 

White's   fielf-retaiiiing   ])alate  retractor 

Applicators    

Tongue-de|)ressor   

Tongue-depressor   

Tongue-depressor 

Sass's    tongue-depressor 

Tiirek's   tongue-(lei>ressor 

Davidson's  atomizers,  to  he  useti  liy  eoni|u-essed  air  or  hand-bull).  .  .  . 

Hurgcsa's  nielaltulie  atomizers:    straight,  up,  and  down 

Mosworth's  atomizer 

Compressed-air  apparatus 

Powder-hlowor  with  mouth-jtieee  and  tube 

Powder-blower    w  ith    bulb 

Powder-blower  with  tubing  and  bulb 

Powder-blower  with  scoop 

IJosworth's    nasal    saws 

Mial's  reversible  saw 

Hartmann's   nasal   chisels 

Freeman's  drill 

Hosworth's   nasal    polypus-siuire 

Sajous's  nasal  polypus-snare 

Hall's  nasal   i)olypus-siiare 

Deneh's  nasal  polypus-snare 

Universal  cautery  and  snare-handle,  with  cannula  and  snare 

Cautery-electrodes  

Nasal  burrs 

Nasal  trepliines 

Beren'a  and  Nichols's  spokeshaves 

(xvii) 


I'A<IK 


I) 

15 

10 

10 

17 

18 

18 

18 

18 

18 

19 

19 

19 

19 

19 

20 

20 

21 

21 

21 

22 

22 

22 

23 

23 

24 

24 

24 

24 

25 

25 

25 

26 

20 

20 

27 

27 

27 

27 

28 

28 

28 


will 


M>l'    111     II.M>II!  \ll(tNS. 


no.  r.\(iK 

•lii.     Aiitciiiir  iliiiiii^<ii|i\ ,  |iii«iti<>ii  ni'  the  IkmiI   I'm    iii-ptii  iti;,'  tlic  wnll  nf 

llic  |iliiii  viix   lliniii;:li   the  iiiwal   iPiixwiijri's 29 

■4.'!.     I'ltstt'iidr  rliimisrii|iic  iiiiii;."'    'M) 

44.     Jl v|i('ili<>|iliy  nf  mi. Idle  :iii(|  iiifi'iinr  t iiiiiiiiiil« 45 

4r>.     Si'fliiJii  nf  iiUVriiir  tinliiiiiilccl    {■!'>  iliiiiiicl(i-.i 40 

4<1.      I,!ir;fi'  iiiii^scs  nf  liy|M'it  ni|iliii'(l  iiH'iiiliiiuic  nil  llic  |)()>ti'riiir  tcniiinii- 
tinll    (if    (he    liivvcr    t  iirltilUltcil    Ikhics,    iikiic    (if    less    coiiiiilcUly 

lillin;,'    tin-    |iii-i«ii(ir    iiiiic-; 47 

■l(i»/.  Aiilci  inr  |iiirliiin  nf  iiifciinr  tiiiliiiial   ('/..iiuli  nliiccliNci 48 

4(i/».   l'(i>l('iior  iiititidii  (if  iiiiVriiii-  linliiiial   (l-iiicli  (iLJcctiN ci 4H 

47.     lialluiil  },'al\aniu-aiit('ry  lialh  ry.  with  fiml.  liamlli',  and   knife 53 

4K.     Knif>lit'N   n!i>ial   scissms fiCi 

4!».     Sliiirly's  nasal   forcc|i« 57 

51).     I'ost  na-al  --yrin;.'!' (i;{ 

5((</.  J'lwl  nasal  syiiii;;r ((3 

5i.     Fm/cn  section  nf  the  head  <if  a  iliild  a<jed  5  years  i  (dlnr  cut ) 77 

5|(/.  I'ldzen  seelinn  nf  ^aiiii'  eliild.  taken  twi  eentimelres  anterior  in   |''ii^, 

51    leolor-eUt  I ~',) 

52.  Seetidii  of  cart  ila;.'iniiiis  -yuv  fnmi  tlie  na-al  septnin   (25  diaineters) .  84 
5.'{.     Silver  tnlies  for  se]ital   defniMiity 85 

54.  Silver  tnlies  for  sejital  deforniity .• 85 

55.  I!ell<i( (|'s  cannula 108 

5(!.      Kliinolitli   reninved   from   the  left    nasal  jiassa^'c  of  a  lady,  ayed  2S, 

nineteen  years  after  the  Insertion  of  the  Imlton  intti  the  nostril.  Ill 

57.  S|ioiin    113 

58.  Hoswiirth's  nasal   forceps 113 

5!».     Allij;ator  for.'cps     113 

fiO.     liartniiinn's   foii-ep-. 114 

til.     Nasal   polypi IKi 

(12.     ^Microscopical  section  of  na-al  polypu-   i2(il(  diameters) 118 

(i3.     !Miei()sco|iieal  section  of  nasal  polypus  from  a  child  7  years  old....  120 

04.     r.lake's  ear  iiolypu-  snare ' " 122 

65.     ("aseous  mass  washed  out   of  antrum  thron;_'li  ostium  maxillare 102 

00.     Lateral  frozen  section  throufrli  the  middle  rejrion  of  the  nose   (color- 

eut.) 103 

67.  I'ileclrie  illuminator  with   llcxihle  shank  and  cords 1()7 

68.  (jironal  section  of  the  maxillary  sinus,  the  suhject  of  cystic  disease.  173 
Oft.     Inlhunniation   of  the  ethmoid   cells,   show  iiii;  jj^lands   to   ri;i;ht   (|uite 

normal  and  those  to  lower  left  hand  more  or  less  altered 170 

7(1.     Sectional  \iew    of  the  ]iharynx 180 

71.  Frozen   secliim.      Side-view    of  nose,   pharynx,   and   larynx   of  child, 

afzed   .'t  years    (color-cut  ! 187 

72.  The  muscles  of  the  soft  ]ialate  and  pliar\n\:    the  pharvnx  laid  open 

from  hehind    .' ' 18!) 

73.  Infantile  ademiids 204 

73«.  Infantile  adenoids   (represents  a  ".nnwth  i|uite  common) 204 

74.  Stalactite  forms 205 

75.  Micrnsco]iical   section  of  hypertrophied  ]iharynf.'eal  tonsil  with  lym- 

jilioid  intiltration   (2(i  diameteria) 20(5 

70.     Adenoid  forcejis   213 

77.  Adenoid  curettes   215 

78.  Dr.  (iranfs  ease  of  ]iost  nasal  jmlypus 217 

70.     Uvula-seissors 255 

80.  Excision  of  uvula 250 

81.  Simple  livpertrophv  of  faneial  tonsil   (57  dianieters) 203 

82.  Mathieu's  tonsillot'omes  208 

53.  PliarynfroTuyeosis  (polor-eut) 277 

84.     Loptothrix.     Adventitious  folliele  to  left  side   (color-eut) 278 


LIIST    OK    ILI.OI  li ATIONS. 


XIX 


Fli..  VM.y. 

S'>.      I,t|il<illiri.\   I//   ■•>■///(    r    ,  illi  ll   iilijccl  ixc;     ccilul-  cut  I i'S 

Hti.     Kfiiilosis  of  tnii-^il  «illi  liptdt  liiix   ('/,;iiicli  (it)j('clivi':    ((iliirciit  i  .  .  27!> 

k7.     llypt  rlmiiliy   "t   tlif   Nil    liii;iiiiil   tonsil 2M 

H'a.  I'.ilatciiil  li\  |ititroi)liy  of  liiiyfiinl  Inn-il    ,  .  .• 284 

HH.     I.iii^iiial    \;iii\    (lolo'r-rut  ) 285 

8!t.     .Mil  ros('o|)i(al  section  of  iolif  of  lin^niiil   tonsil 280 

!)().     Itoc's   lin;;iiiil    ton>illoti.nH' 288 

!•!.     I.nims.     I'alntiil  a|i|icaiancc 2f)7 

\t±     l.n|iiis   of   linjrinl    tonsil    ('/.riiidi   olijcdivc;     Klirlich-lUondi    stain: 

color-cut  )     -Jiis 

'Xi.     Lupus   of   lin^'ual    ton-il    ('     iiidi    olijiiiivc;     I'lirlicli  lUonili    ^-tain; 

color. Ml  I     •-'!"•» 

!tt.     Malijiuanl     i  iiitliclionia,    cxtcnilinj;    fn  ui    rij,'lit    tonsil    to     liasc    of 

1oii;.'U('    .  .  •'Ml 

!»").     Stialilii  (1  c|iitliclioiiia  of  lon-ils  (''.-inch  ohjcclivci    ,\\'l 

!)')(/.  Kpitliclionia   show  inj;  cell  iicsts    ('/..-incli   olijcctixc  i    :i\'A 

(tli.     ]{()l)crt son's  calculus  fimn   ri^zlil    ton-il .'!'J"J 

!•?.     1  lu'   laifilafiinous   frame   of   iIk'   larynx,    with    the    hyoiti    Imne   ami 

li^'amcntous  atlachiiients   .'t2S 

ftS.     'I'he  crii'oid,  seen  anteriorly .■{2i» 

fli>.     The  cricoid,   u]i|ier  surfiiee .T2!l 

KM).     The  cricothyroid   niuscle,  \ic\\ed  anteriorly 'V,W 

lOtV/.  'J'he  \<ii(c  hox.  or  larynx,  seen  from  liciiiiid X\\ 

1(11)6.  ^'ie\\   of  the  \di<-e  lioN,  or  laiynx,  cut  open  from  liehind UHl 

101.  'J"hc  arytenoid  and   posterior  cricoarytenoid   )nuscles 'i'.i2 

102.  Side-view  of  tne  larynx.  -ho\\in;r  the  interior,  the  ri^rht    plate  of  the 

thyroid  lieinif  removi'd 'Mi 

lO;?.     The  lar\  Uiioscopic  inia;.'e  diiiin;:  respiration 338 

104.  The  laiyn;roscopic  imajre  duiiiiLr  phonatioii 338 

10.').     l,ai-yn;,'eal  and  posl-rhinoscopic  nnrrors ;!ti» 

lot).     The    hirvnf;eal    mirror   in    |iosiiion    (Cohen)    when    held    liv    tin;    left, 

haiid  ■ 341 

107.     Position    for   aiitoseopy 345 

105.  .\ulovcope  w  ith  jihite  instead  of  hood 34(5 

100.     .\ntoscopie  o|icration    347 

110.  Tonj,'Ui'-(lepre-sor  for  ]pharynj:oscopy  and  dircit  iarynf;otracheo>copv.  'MS 

111.  O'Duyer's  int  nhal  ion-set   '. ." " " .  350 

112.  Instruments    for   intwliation 351 

113.  Plated    iraeheotoiiiy-tnlK"    354 

114.  Hard  rnldier   tracheotomytulie    355 

115.  Klsl)er<ir's   t  lacheotomy-tulie    355 

W'lit.  Hank's  tracheotomy  tnhe    35(i 

1  Hi.     Low    traeheotomv    (color-cnf  > 350 


'J'lnrotomv    (eolor-cnt  i 350 


I'. 


I, 


1. 


iiryufroscopK'   appearance 


123.     l.upns   of  the   opifflottis    (Vn-i'H'h   objective;     Khrlidi-Hiondi    stai 


eoloi- cut ) 


400 


407 


124.     I.upus   of   the  epijjlottis    ('/.-inch    ohjective;     Khrlicli-Miondi    slain: 


ef)Ior-eut.)     408 


125.     l.ejirosy  of  the  tonijue  and  epiglottis 413 

12(!.     Destnietion  (,f  cpifrlottis  from  s\philitie  ulceration 415 

41(1 
410 


127.  (  ieatricial  stenosis  of  larynx,  tlie  result,  of  syiihilitie  idceratic 

128.  Lennox  Browne's  hollow  larviiwal  dilator  with  enttiiifr-tjlade 


129.     P«i)illonui  of  cord  during  rps))iration 420 


XX 


LIST    (»K    Il.I.USTHATlONS. 


no. 

130. 
131. 
132. 
133. 
134. 
135. 
130. 
137. 
138. 

139, 
140. 
141. 
142. 
143. 
144. 


Sumc  during   plionalitui 

Fibroma  situatt-d  hcncutli  tlie  rifjiil  vonil  lord 

Chondroma  of  Mip  epiglottis 

Angioma  of  the  left  arjepiglottic  fold 

Kxtirimtion  instruments   

Sarcoma  of  tlie  larynx,  as  seen  from  heliiiid 

Tooth-jihite   in  glottis 

Tooth-iilate  removed ; ;  /    ;  • 

Laryngeal  polypus  forci-ps,  Maeken/.ie'.-,,  revolving,  with  three  altaeli- 

ments 

r.aryngeal   polypus  forceps,    \\  axliam's 

Laryngeal  polvpus  forcc)s,  I'raeiikcrs,  culling  jaw 

Laryngeal  polypusforcf  ps,  Mackcii/.ic's,  articulated 

Load  iilate   for  nasal  uveli 

Steel  pill  for  nasal  transfixion 

Nasal  ajiplianie  in  i"Hit ion 


'.VOB 

429 
43U 
431 
431 
433 
43(i 
442 
443 

444 
444 
44r) 
445 
449 
449 
451 


r.voK 
421) 

.  4ao 

.  4:u 

.  4:u 

.  4:j:» 

.     431) 
.      44-2 

.    4»;j 

444 
.     444 

445 
.     445 

44» 
,  44i> 
.     451 


S1{(TI{)N  I, 


Diseases  of  the  Nasal  Passams. 


f 


I  llAITKIf   I. 


ANATOMY  OF  TlIK  KXTKKVAl.  NOSH,  NASAI.  PASSAGES, 
AM)  A(  (  KSSOIiY  SINLSKS. 

TilK  outer  iKxi'  ('(insi.-ls  nf  ilic  \i«ililc  jinriiim  nT  that  organ, 
t'omposed  of  lioiu's,  cartilajics,  lilmtii.-;  tissue,  umsck's,  integument, 
and  mucous  inemhraiu".  It  contains,  within,  the  two  vestihulae,  sepa- 
rated from  eaeh  other  perpentlieularly  hy  tlie  anterior  portion  of  tlie 
trianguhir  cartihige  (Fig.  1)  and  tlie  iiiti'rnal  union  of  tlie  h>wer  lateral 
cartilages. 

The  lateral  wall.s  are  Torined  liy  tin'  nasal  hones,  and  the  nasal 
processes  of  the  superior  ma.xillary  Ixmes,  together  with  the  upper 
and  lower  lateral  and  sesamoid  cartilages. 

The  septum  dividing  the  two  nas^al  cavities  from  each  other  is 
formed  directly  helow  the  triangular  cartilag<\  already  mentioned,  hy 
an  additional  narrow  slip  of  cartilage  at  the  entrance  of  the  nostrils, 
termed  the  "columnar  cartilage." 

The  openings  of  the  anterior  nares  are  usually  on  a  lower  level 
than  the  floor  of  the  nosi";  and  they  are  also  ]»rotectod  hy  a  "  "her 
of  stilf  hairs,  or  vil)rissa>,  which  line  the  nostrils  and  the  vesihuio. 

The  various  muscles  of  the  nose  are  attached  to  the  external  walls 
and  are  for  the  i)urpo.>o  of  dilation  and  contraction  of  the  nostrils 
and  for  the  elevation  and  depression  of  the  orjran. 

The  nasal  fossa3  are  two  cavities  ahout  equal  in  size,  extending 
from  the  nostrils,  or  anterior  nares,  directly  hackward  to  the  naso- 
pharynx, and  entering  it  hy  the  posterior  nares,  or  choanas,  as  they  are 
sometimes  called.  These  cavities  vary  very  much  in  size,  the  average 
depth  from  heforc  hackward  in  the  adult  heing  ahout  5  centimetres, 
and  the  height  3.5  centimetres  in  the  centre  of  the  fossie.  The  sum- 
mit of  the  vault  on  each  side  is  only  a  narrow  chink,  arching  from 
the  front  to  the  hack;  while  the  floor  runs  almost  horizontally  hack- 
ward,  with  a  surface  varying  hetween  1  and  1  Vj  centimetres  in  width. 
The  external  walls  of  the  passages  slant  irregularly  outward  and 
downward  (Fig.  2). 

(3) 


4 


i)isi;.\si;s  OK   jin:  ^.\^Al.  tassagls. 


Tlio  si']iliiiii  divides  the  fossji'  fi'oiii  caoli  other  from  front  to 
back.  ]{  is  fiiniicil  of  ilic  Iriaii.uuhu'  cartila.L;  ■  in  front,  the  pcrpen- 
dicidar  ]ihitc  of  the  I'thiiuiiil  in  ihc  nppi'r  portion  behind,  with  tlie 
vomer  inuiicdiately  heiicatii  it.  In  eaily  lilV  the  septum  usually  oc- 
cujiies  its  natural  eeniral  jiosilion;  diii'iiii;-  youth  and  eonimeneing 
Jiiaturity  it  very  fre(iuently  heeonies  delleeted  in  some  part  of  its  course. 


Fig.  1. —  (■utiliiLic^  111  I  III'  iiiiM',  x'cii  ill  ]ircililL'  (Ijapin'yj.  1,  Right 
lateral  cartilage,  li,  Its  aiiterim-  lionler.  ."i,  .\n  aecofsory  cartilaginous 
nucleus  attadied  t<i  the  iiilVrinr  JKirilcr  "f  the  same  eartilago.  4,  Anterior 
accessory  eartilages  reiiiarkalile  fcir  their  nvnidal  form  anil  tlic  constancy 
of  tlicir  existence.  5.  lv\teriial  Inaiieh  of  the  alar  cartilage.  (I.  Union  of 
this  branch  with  the  infernal  liraneh.  7,  S,  f),  Seeonilary  rartilaginous 
branches  added  to  the  external  braiieh  of  the  alar  cartilage.  10,  .\cccssory 
cartilage  not  constantly   found.      (.Vfter  Bosworth.) 


•'i 


The  onter  walls  of  tin-  nasal  fossa'  are  formed  from  before  back- 
ward by  the  nasal,  the  siijierior  ma.xillary,  the  laerymal,  the  ethmoid, 
the  palate,  and  the  iiilernal  ptery,<:oid  plate  of  the  sphenoid.  At- 
tached horizontally  to  this  bony  wall,  arranged  from  above  downward, 
are  tliree  scroll-like  bones:    the  superior,  the  middle,  and  the   in- 


I 


t 


AS  \H)\\\  <ii     1  III:   N(i-i;.  6 

IVrinr  turbinatt'ds.  Tlie  sii|n'riiir  lurliiiialnl,  dcsi'dnliiii,'  vertically 
from  the  cribriform  plato  ol'  the  cthninid,  is  imly  nidiinontary  in  form. 
The  middle  turbinated  is  hirircr,  and  lias  its  (iri.uin  in  the  lateral  mass 
of  the  ethmoid.    'I'he  inferior  turliiiialrd.  iiiiicii  larger  llian  the  middle 

I 

0 - /-^W/Vf^flBj  I 

8 :.^rSi^^ra!fflE^ySS!Mttiii:r":^"  '^ 

I'i.ir.  2.— SM^riltii]  s.Tiidii  III  ~kiill.  JihI  m  ihc  liijiit  „f  tlio  sciitiiin. 
showiiif,'  riglit  imsMl  fcis>ii.  I.  Iiui-dv  cidinl.  i?,  limd  palate.  :t,  4,  Parts 
of  median  cnis  of  thr  caiiila^r,.  ,,f  tlic  a]iiitiiiv.  .">.  Aiitciidi-  part  of  tlio 
same  eartilaf;,-.  (I,  Caiiila^.'c  <>i  the  sc|itiiin.  7.  (iniuvc  'cadin;,'  to  niidilio 
meatus.  8,  Aa-;y,T  nasi.  !i.  |-nni(ai  sinus.  10,  Inferior  etlmioid  eomlKi. 
11,  Superior  etlunoiil  eonelm.  1',/^  Snperinr  meatus  or  etlimoid  fissure.  12, 
Recess  of  uiner  meatus.  i;{.  Vjitranee  t<>  spliemiid  sinus.  14,  Pituitary 
fos.sii.  15,  Sphenoid  sinus,  id.  inferior  turliinal  (nnixilhiry  eoneha).  17, 
Rod  passed  into  Kustaeliian  tube.  IS,  Salpinj.'o-])lnuyn-roal  fold.  10,  Soft 
palate.     20,  Ivulji.     21,  Tonjiue.      (.\fl.r  henm.x   Hrow  tie,   IS't!).) 


6 


])isi;.\si;.s  oi'  thk  nasal  passaciks. 


one.  extends  right  through  tlio  nasal  cavity  from  front  to  back  along 
the  hony  wall,  and  is  attached  to  tlie  othiiioid,  the  superior  maxillary, 
the  lacrymal.  and  the  j)alate  hones.  The  s])ace  between  the  sujierior 
turbinated  and  the  middle  one  is  called  the  sujterior  meatus;  tliat  be- 
twci'U  the  luiddle  and  iul'crior  tuiliiuateils.  the  uiiddie  meatus;  and  the 
lloor  of  the  passage  behiw  the  inferior  turbinated,  the  inferior  meatus. 
Tlie  roof  is  formed  by  the  up))cr  portion  of  the  nasal  bones  in  front,  and 
the  cribriform  plate  of  the  cthmoii!   behind:    the  lloor  by  the  liori- 


12   — 


Fifj.  3. — Anterior  scctidii  nt'  tlic  iiostiils  ( Liisi'hka).  1,  Septum  of  llie 
narcs  iit  position  of  tut)er(le.  li.  Micklli'  luibinatcd  l)0(ly.  ',i,  Inferior  t  ,- 
binated  l)0(ly.  4,  Suiicrior  turl)iiiat('<l  lindy.  fi.  Superior  meatus.  G,  Middle 
meatus.  7,  Inferior  meatus.  S.  Itespiratory  jiortion  of  tlu>  nares.  9,  Olfac- 
tory portion.  10,  Floor  of  the  nares.  11,  Cavity  of  right  antrum.  12, 
Opening  from  antrum  to  nostril.  i;{,  Kthnioid  eells.  14,  Hoof  of  the  nasal 
f()Msa>.  If).  Floor  of  the  nnsal  fossa'.  10.  Cavity  of  oibil.  (After  Lennox 
l^rowne,  18(10.) 


zontal  processes  of  the  suj»erior  maxillary  aiul  [)alate  bones  (Figs. 
3  and  4). 

The.  accessory  cavities  or  sinuses  are  the  frontal  sinuses,  the 
sphenoid  sinus,  the  ethmoid  cells,  and  the  antra  of  Highmorc,  all 
opening  into  the  nasal  cavities. 

I'.acu  frontal  sinus  opens  into  the  corresponding  middle  meatus 
by  a  luirrow  canal  called  the  infundibulum. 


I 


ANATOMY    OF    THE    NOSli.  7 

The  sphenoid  sinus  is  divided  into  two  irregularl} -snaped  cavities, 
situated  in  the  body  of  the  splienoid;  Ihoy  are  separated  from  each 
other  by  a  tliin  septum  of  bone.  The  canal  into  each  communicates 
with  tlic  superior  meatus  of  the  corresjuuidinir  side.  Tlie  opening  is 
usually  not  more  than  a  millimetre  in  diameter;  and  the  roof,  sepa- 
rating the  sinus  from  the  brain,  nut  mure  than  two  millimetres  in 
thickness  (Fig.  5). 

This  sinus  stands  alone;  and,  while  it  is  more  difficult  to  reach, 
its  isolation,  fortunately,  renders  it  less  liable  tu  disease.  The  two 
divisions  of  the  sinus  are  rarely  equal  in  size;  and  the  septum  is 
frequently  to  one  side  of  the  centre.  The  ostium  on  each  side  is 
high,  although  less  elevated  relatively  than  the  ostium  maxillare. 

An  important  feature  to  remember  about  the  sphenoid  sinus  is 


'n 


the 
all 


Fig.  4. — The  posterior  rliinoscopic  iiiiayc.  i,  St'pluni.  2,  Middle  tur- 
binated bone.  3,  Inferior  turbinuted  bone.  4,  Superior  turbinated  bone. 
5,  Superior  meatus.  G,  Middle  meatus.  7,  Inferior  meatus.  8,  Main 
passage  of  nostrils.  9,  Vault  of  pharynx  and  pharyngeal  tonsil.  10, 
Cushion  of  soft  palate.  II,  Posterior  surface  of  uvula.  12,  Jtidgc  formed 
by  levator  palati.  13,  Salpingopharyngeal  fold.  14,  Salpingopalatine  fold. 
15,  Eustachian  pioniineiice  or  cushion.  1(1,  Fossa  of  Rosenmiiller.  17, 
Eustachian  orifice.     (After  Lennox  IJrosMU',   18!)!>.) 

its  near  rel-ation  to  the  cavernous  sinus  and  nerves  i)assing  into  the 
orbit. 

The  ethmoid  cells,  situated  in  the  lateral  ma.<s  of  the  ethmoid, 
are  irregularly  divided  into  the  anterior  and  jiosterior,  the  former 
opening  by  minute  orifices  in  the  neighborhood  of  the  hiatus  semi- 
lunaris and  the  latter  into  the  back  part  of  the  sujieriur  meatus. 
These  delicate  bony  cells,  strung  together  like  a  chain,  are  distin- 
guished by  t!;eir  thin,  ])aper-like  walls,  which  become  more  attenu- 


8 


DISK  ASKS   OF   THE   NASAL   PASSAGES. 


IP 


aled  with  advancing  years.  Tliov  form  a  s])ocies  of  labyrinth,  and 
are  almost  in  direct  communication  with  the  orbit,  the  partition  being 
sometimes  perforated  from  incomplete  ossification.  The  lining  mem- 
brane is  exceedingly  tliin  and  practically  free  from  glands  (Fig.  3). 

The  inaxillanj  sinus,  or  antrum  of  Ilighinore,  is  situated  in  the 
body  of  the  superior  maxillary  bone.  It  is  pyramidal  in  shape  and 
the  largest  of  the  accessoiy  cavities— often  large  enough  to  hold 
many  grammes  of  fluid.  Kach  antrum  has  one  opening,  situated  on 
the  upper  portion  of  the  internal  or  nasal  wall,  called  the  ostium 
maxillarc,  and  located  in  the  middle  meatus  (Figs.  3  and  5). 

This  sinus  is  lined  throughout  with  mucous  membrane,  closely 
adherent  to  the  periosteum.  This  is  of  the  columnar  ciliated  and 
chalice  epithelium  type.  Although  the  antral  mucosa  is  about  twice 
the  thickness  of  that  in  the  other  sinuses,  yet,  like  them,  it  is  almost 
free  from  glands.  What  there  are,  histological  examination  has  proved 
to  be  of  the  tubular  variety.  The  two  antra  frequently  differ  in  size. 
Zuckerkandl  has  found  supernumerary  apertures  in  a  number  of  antra; 
but  these  are  too  small  to  be  of  physiological  importance. 

The  maxillary  antrum  differs  from  the  other  sinuses  in  several 
impoi'tant  particulars:  1.  It  is  very  much  larger  in  size.  3.  The 
only  opening  into  it  is  in  the  upper  portion  of  the  sinus,  whereas 
in  the  other  sinuses  the  openings  arc  always  upon  a  lower  level.  3. 
It  is  more  prone  to  early  disease,  owing  to  the  frequent  encroach- 
mrtit  of  dental  caries  and  also  to  the  absence  of  dependent  drainage. 

The  lacrymal  duet  opens  ijito  the  inferior  meatus  below  the  front 
end  of  the  inferior  turbinateil. 

The  mucous  membrane  .f  the  nasal  cavities  is  continuous  with 
that  of  the  pharynx  and  the  Flustachian  tubes,  and  extends,  in  turn, 
to  all  the  accessory  sinuses.  It  is  formed  in  three  layers:  First,  the 
surface-epithelium,  comjiosed  of  ciiithelial  cells  of  the  columnar 
variety,  extending  over  tlu'  u]i]ier  half  of  the  septum,  and  the  supe- 
rior turbinated  and  pnit  of  the  midille  turbiiuited  bones;  and  of 
ciliated  cells  over  the  lower  part  of  the  septu!n  and  tile  remainder 
of  the  turbinal  surfaces.  Second,  the  true  mucous  membrane,  com- 
posed of  white,  fibrous,  elastic,  connective  tissue,  inclosing  within  it 
blood-vessels,  smooth  muscular  fibres,  serous  and  mucous  glands,  with 
tubular  orifices  opening  upon  the  epithelial  surface.  Third,  a  sub- 
mucous layiT  of  connective  tissue,  very  loose  in  form,  and  lying 
directly  upon  the  periosteum  and  perichondrium  of  the  nasal  frame- 
work.    It  is  composed  largely  of  venous  sinuses  studded  with  tu- 


Ki^.    .").       I'|(i/cll     -eel  inn     nl     |i(M(|     i(|'    ildllll.        I.     Iliijlil     and     Icl'l     optic 

niTvi-;.  li.  S|ilicMcMil  sinii^  Willi  ]i(isl('ri(ir  wall  icninvcd  ;!.  S|iliiiiiiid  -inn-* 
with  j>i>«tcri<ir  uiilj  in  |iii-iiiiin.  4.  I.dt  nii-:ii  l(i--ii.  ,■"),  \a-:il  -cptiini.  li. 
Ilitilil  iiil'crini-  iinlnnaicil  l)(inr.  i  I'rmn  I'l  iniid-c'^  An.ildiniial  .Mn-iiini. 
I   niMi^itv     111'     Inicinlu.i 


I  i 


ANATOMY    OF    TlIK    NOSK. 


11 


biilar  niiiooiis  gland:^,  and  lias  it.s  liighest  (levolopiuL'iit  ov{;r  the  tur- 
binated bones,  particularly  upon  the  middle  and  posterior  portions 
of  them — forming,  with  the  middle  layer,  the  so-called  corpora 
cavernosa  nasi.  The  mucous  memi)rane  of  the  middle  and  inferior 
turbinatods  dilTers  from  the  remaining  surfaces  in  this  respect:  the 
rich  endowment  of  blood-vessels  and  muciparous  glands  enabling 
tliem  to  perform  so  freely  their  physiological  function.  The  color 
of  the  columnar  epithelium,  in  the  mucous  membrane  of  the  npper 
portion  of  the  nose,  is  yellowish  pink;  that  of  the  lower,  or  ciliated, 
region,  from  its  richer  blood-supp'y,  is  reddish  pink;  while  the  pos- 
terior ends  of  the  inferior  [urbinatcds,  [larlieularly  when  much 
swelled,  are  of  a  whitish  or  ])urplish  hue. 

The  Nerves. — The  innervation  of  the  nose  is  of  a  dni'ble  char- 
acter: the  one  consisting  of  the  special  sense  of  smell,  the  other  of 
ordinary  sensibility.  The  former  is  supplied  by  the  olfactory  nerve, 
which  i)asses  by  many  minute  filaments  through  the  cribriform  plate 
of  the  ethmoid,  and  is  distrilnited  ovei*  the  upper  third  of  the  septum, 
the  superior  turbinated,  and  the  upper  half  of  the  middle  turbinated, 
terminating  in  the  rod.  or  olfactory,  cells  of  Scluiltze,  which  arc  con- 
sidered to  be  the  special  terminals  of  the  olfactory  nerve-fibres.  The 
latter  is  abundantly  supplied  by  superior  nuixillary  braiu^hes  of  the 
trigeminus  and  the  nasal  l)ranch  of  the  ophthalmic  and  some  fila- 
ments from  Meckel's  ganglion. 

lilood-vcssrls. — The  vascular  supply  to  the  frontal  sinuses,  eth- 
moid cells,  and  roof  of  the  nose  is  derived  from  the  anterior  and 
posterior  ethmoidal  l)ranches  of  the  ophthalmic.  The  sphcno-palatine 
branch  of  tlie  internal  maxillary  artery  supi)lies  the  mucous  mem- 
brane of  the  turbinateds  and  septum,  while  the  alveolar  branch  of 
the  internal  maxillary  sup])lics  the  antrum. 

(IJainls. — The  upper,  or  olfactory,  area  of  the  nose  is  said  to  he 
relatively  more  richly  glandular  than  the  lower,  or  respiratory,  area; 
and  one  function  of  the  exosmosis  being  merely  to  keep  the  sensory 
nerve-filaments  in  a  constantly  moist  condition,  these  glands  are  almost 
solely  of  a  serous  character. 


CIIArTKU  Jl. 

niYSIOLOGY  OF  THE  NOSE  AM)  ACCESSORY  SINUSES. 

Within  the  last  liair-coiitiiry  it.  was  the  general  impression,  even 
among  medical  men,  that  the  nose  had  only  one  important  funetion 
to  perform,  and  that  was  to  preside  over  the  sense  of  smell.  Now 
it  is  kn(jwn  to  perform  tliree  important  fuiictinns.  dl'  which  olfaction 
is,  perhajis,  llie  least.  'J'hc  otiiers  are  to  give  heauty  and  resonance 
to  the  voice  and  to  perform  a  comjilex  duty  in  I'cfcience  to  respira- 
tion. 

Tiih  Sknsk  of  S.micll. 

Tlie  sense  of  smell  is  produced  hy  infinitesimal  particles  of 
odorous  hodies  being  drawn  into  ihc  nasal  cavities  during  insj)iration. 
They  arc  there  dissolved  by  the  nasal  mucus  and,  coming  in  con- 
tact with  the  terminal  filaments  of  the  olfactory  lUM'ves,  a  sense  of 
their  presence  is  at  once  transmitted  to  the  nerve-centre  and  their 
odorous  qualities  recognized.  Dry  particles  on  dry  membrane  are  not 
])erceived  by  the  nerve.  ]Icnec  the  importance  of  the  nasal  mucosa 
being  in  a  healthy  moist  condition.  In  the  same  way  the  presence 
of  crusts  or  tumors  or  foreign  bodies  within  tlie  nasal  cavities,  by 
preventing  the  contact  of  odorous  particles  with  the  sensitive  mucosa, 
mars  the  full  observance  of  this  iinjjortant  function.  In  order  to 
insure  a  perfect  sense  of  smell,  the  nerve  itself  must  be  in  a  healthy 
condition. 

Frecjuently  in  prolonged  and  chronic  nasal  disease  the  terminal 
filaments  lose  their  normal  sensibility,  and  this  loss  of  functional 
power  affects,  to  a  marked  degree,  the  sense  of  taste,  as  well. 


Tun;  Nose  in  Piionatiox. 

This  organ,  in  conjunction  with  the  nas()-i)liarynx,  has  a  very 

important  influence  upon  the  formation  of  the  voice,     ('ombinedly 

they  act  as  a  resonance-chamber  in  which  ihe  voice,  after  passing 

through  the  vocal  cords,  receives  its  final  tone.     All  vocal  sound  is 

(12) 


PHYSIOLOGY    OF   THE   NOSE. 


18 


])rocliuc(l  by  vibrations  of  a  euluran  of  air  issuing  thiougli  the  glottis. 
Tlie  pitch  of  tone  is  regulated  by  the  tension  uf  the  cords;  the  volume, 
by  the  force  with  which  the  column  of  air  i.>  driven  tlirough  them; 
wliile  the  cliaracter  or  individuality  of  the  voice  itself  is  dependent 
largely  upon  the  mouth,  pharynx,  and  the  formation  of  the  nasal 
ciuunbers. 

Tlie  soft  palate  has  a  great  deal  to  do  with  correct  phonation, 
and,  to  perform  its  duties  well,  should  be  perfectly  free  from  ob- 
structive lesions,  either  in  tlie  naso-pharynx  above  or  the  tonsillar 


region  beneatli. 


TlIH    XOSE    IX    IJESl'inATIOX. 


is 


Tile  triple  function  of  saturating,  cleansing,  and  heating  the 
uir  of  respiration,  as  it  passes  through  the  nasal  fossic  to  the  throat, 
is  probably  the  most  important  of  all  the  duties  which  Nature  has 
assigned  to  this  organ.  It  luis  been  i)roved  by  experiment,  over 
and  over  again,  that  ordinary  dry  air,  containing  only  a  minimum 
of  moisture,  becomes  saturated  as  it  passes  through  the  nose  during 
inspiration.  This  added  moisture  is  olitained  from  the  serous  exuda- 
tion of  the  mucous  membrane  of  the  turbinateds.  This  fluid  exudes 
from  the  cavernous  sinuses,  caused  by  the  stimulation  of  the  air  as 
it  ])asses  over  them,  and  is  sliglitly  diluted  by  the  mucus  from  the 
tubular  glands.  These  venous  jilexuses,  which  perform  so  important 
a  function,  are  named  by  Zuckerkandl  Scliicellkorper,  or  swell  bodies. 
In  a  healthy  condition  they  are  fully  surcharged  with  blood,  and  the 
serum  passes  out  by  transudation,  to  be  absorbed  by  the  air  during 
inspiration. 

The  amount  of  moisture  thus  given  of!  by  the  healthy  nose  in 
twenty-four  hours  is  estimated  at  about  one-third  of  a  litre  and,  as 
can  readily  be  seen,  plays  an  important  part  in  the  ])henomcna  of 
normal  breathing.  To  in,sure  this  supply  of  serum,  the  sinuses  of 
the  turbinateds  are  always  filled  with  blood,  yet  this  hypera?mic  con- 
dition, normally,  is  not  sulTicient  to  produce  stenosis  of  any  part. 
Kverywhere  throughout  the  nose,  however  tortuous,  these  narrow 
passages  are  open;  and  the  air  of  respiration  becomes  saturated  while 
]iassing  through  them. 

At  t'.'"  same  time  the  air  becomes  elevated  in  temperature  by 
contact  wiui  the  hot,  moist  walls,  being  many  degrees  nearer  blood- 
heat  by  the  time  it  reaches  the  pharynx  than  it  was  on  entering  the 
anterior  nares. 


n 


DISEASES    OF    Tllli    NASAl.    I'ASSAtiKS. 


Tlien,  also,  tlie  air  is  inirificd  as  it  passes  throu]ij:]i  the  nasal 
})a?sagc>.  Insects,  heavy  dust,  and  minute  foreign  hodics  are  hirgcly 
kept  out  by  the  fringe  of  vibrissa',  wliieh  stands  guard  over  tlic  en- 
trance to  eacli  nostril.  It  is,  however,  the  moist  nasal  mucosa  which 
does  the  chief  part  of  tiie  cleansing,  the  myriads  of  leucocytes  and 
mucous  cells  acting  as  phagocytes  and  destroying  the  invading  hosts 
of  noxious  germs  as  they  advance  backward  from  the  vestibule.  U.  L. 
AVagner  says:  "The  action  of  these  leucocytes  docs  not  consist  in 
their  total  destruction,  but  in  greatly  diminishing  their  activity." 
Whether  the  normal  mucous  secretion  is  a  germ-destroyer  or  not  is 
still,  in  some  degrees,  an  open  question,  pathologists  differing  upon 
the  sul)ject.  Still,  one  thing  is  certain,  that,  whereas  the  mucus  of 
the  vestibule  is  always  loaded  with  microscopical  germs,  that  in  tlio 
back  ])arts  of  the  normal  nasal  passages  is  almost,  if  not  entirely,  free 
from  them.  It  is  possible  that  a  great  deal  of  the  cleansing  process 
is  (Inc.  however,  to  the  oft-repeated  etTorts  of  Xalurc  to  eject,  by 
forcible  exjtulsion,  anything  that  irritates  the  nasal  passages. 

The  special  function  of  tlu'  large  antra  of  Ilighmore  is  probably 
one  of  jilionation.  Filled,  as  they  are.  by  air  when  in  a  healthy  con- 
dition, with  free  openings  into  the  na«al  chambers,  they  may  give 
additional  vibration  and  tone  to  the  voice,  whether  in  vocal  exercise 
or  ordinarv  use. 


■:* 


CHAl'TKK  IIJ. 

INSTRUMENTS  USKI)  FOR   JllK  KXA.M  I  NATION  AND  TKi:  \T- 

iAIKNT  OF  Dl.SEASFS  OF  TlIK  NOSE 

AND  TIIHOAT, 

Fou  tlie  successful  examination  and  treatment  of  nasal  iliseascs 
we  require  the  aid  of  arfiflcial  light,  either  reflected  from  an  electric 
lamp  i)laced  on  the  forehead  of  the  surgeon  (Fig.  0)  or  from  hricrht 


Fig.  C.-Phillips's  electric  pl.otophone,  with  adjustment    fm- 
focusing  liglit. 

"light  of  some  kind  placed  on  either  side  of  the  patient  and  relh^.ted, 
from  the  head-mirror  of  the  operator,  upon  the  part  to  he  examined 
(tigs.  7  and  7a). 

The  ordinary  plan,  and  the  one  largely  adoj.ted  hy  specialist^ 
Jip    0  the  present  date,  is  the  latter  one.    The  light  should  he  on  a 
level  with  the  patient's  nose,  and  on  a  plane  a  little  posterior  to  it 
Ihe  surgeon  sits  immediately  in  front  of  the  patient,  and  hy  adjust- 

(15) 


1 


IG 


DISKASKS    OF    TllK    NASAL    I'ASSAdKS. 


Fi".  7.     lli'iid  niirrcr. 


i         1 


Fig.  7«. — Ilead-niirror  in  position. 


ing  the  head-mirror  the  fociis  of  light  is  thrown  directly  upon  the 
spot  to  be  observed.    The  advantage  of  this  arrangement  is  that,  by 


INSTIMMIAIS    AM)    TIIICIK    ISi:!*. 


17 


looking'  with  oiie  I'Vc  lhroii;rh  the  hole  in  tiic  mirror  and  with  tlic 
otluT  past  its  odjic,  lie  ciitiri'Iy  escapes  any  direct  rays  of  the  lij^ht 
from  falHn^  upon  his  own  retina.  The  eiiaracter  of  the  lif^dit  used 
is  of  some  ini]»ortan('o.  An  inclosed  li^dit  in  a  dark  corner  of  tlic 
room  is  host.  The  li<,dit  itself  shoidd  he  hri<:ht,  clear,  and  steady, 
placed,  if  possihle,  in  a  MacKeiizie  concentrator  or  one  of  the  more 
modern  forms  (Kijr.  >^).     It  may  he  hy  electricity,  gas,  or  nil.     I'lven  a 


Fig.  8. — Laryngoscope,  gas-stand,  mirror,  condcnsiT,  and  tubing. 
(After  MacKenzie.) 


tallow  candle,  if  notliin;;-  l)etter  can  be  obtained,  may  be  of  good 
sen-ice. 

For  anterior  rhinoscopy  tlic  nasal  speculum  is  rccjuired,  the  ol)- 
ject  being  to  open  the  nostril  painlessly  to  its  widest  capacity  for 
the  admittance  of  light.  Of  this  instrument  there  arc  many  varieties, 
of  Avhicb  Figs.  9  to  13  are  samples.  Each  surgeon  must  make  his  own 
choice.  I  have  found  those  of  an  ovoid,  cylindrical  form  much  the 
most  convenient,  protecting  the  nostril  and  admitting  abundance  of 


18 


DISEASES    OF    THE    XASAE    PASSAGES. 


liglit.     Some  like  a  spring-wire  instrument.     Shurly  considers  a  spe- 
cial protection  to  the  nasal  wall  opposite  to  the  side  operated  on  to 


Fi<ir.  9.— I'osworth's  huge  and  small  nasal  specula. 


Fiy.   10. — tJoodw  illio's  nasal  speculum.        Fig.   11. — Myles's  nasal  sjjoculum. 


^ 


'K 

.•:!,. 


Fig.  12.— Siniitick's  nasal  speculum. 


^^f 


Fig.  13. — Sincrock's  nasal  speculum,  with  handle. 

be  an  essential,  and  has  devised  the  instrument  shown  in  Fig.  15  for 
this  purpose.  Bosworth's  Fig.  11  is  formed  in  a  somewhat  similar 
manner. 


I 


INSTRUMENTS   AND   THEIR   USES. 


Fig.   14.-Bosworth's  nasal  speculun,,   with  shield 
for  cautery-work. 


■-•^lii^j^ 


Fig.  15.— Shurl.v's  nasal  speculum. 


19 


Fig.  io-Po3t-rhinal  niirn 


or. 


Fig.  17.-Post-rhinal 


mirror. 


Fig.  18.-VVhite'8  self-retaining  palate 


retractor. 


I 


20 


DISEASES   OF   THE   NASAL   PASSAGES. 


For  posterior  rhinoscopy  posterior  rliiiial  mirrors  of  small  sizes 
are  required  (Figs.  16  and  17),  and,  to  facilitate  post-pharyngeal  ex- 
amination, various  palate-retractors  have  also  been  introduced  (Fig. 


Fig.  19. — Applicators. 

18).  The  latter  arc  rarely  nccespary,  as  l)y  a  little  practice  on  the 
part  of  the  operator  and  training  on  the  part  of  the  patient  nios!: 
pharyngeal  and  {)o.st-r]unal  cavities  can  be  examined  without  tiioir 
aid. 

To  these  might  he  added  o()l(on-aii[)li('ators  or  prol)os   for  tlic 


;  t 

'I 


■^ 


Fig.  20. — Tongue-depressor. 


application  of  solutions  and  cleansing  of  the  passages  (Fig.  19),  anci 
tongue-depressors  to  facilitate  examination  of  the  post-nasal  region 
(Figs.  20  to  24). 


IX.STRa.MENTS    AND    TIIKIR    USKS  gj 

1.  Atomizers  to  throw  sprav  wifhin  iU  ,      "• 

'P''i>  witliui  the  nasal  cavities,  anteriorly 


Fig.  21.--Tongiie-(lci) 


J)i-c.ssor. 


Fig.  22. ' 


rongne-depiosaor. 


Fig.  23.-Sass'.s  tonguo-doprcssor. 

'■"  H.o  purpose  (Fis.  Jy'"'''"'''"'^  «"■  f™m  f=nl-s  specially  devised 


t; 


1 1 


i  1' 


22 


DISKASKS    or    TIIK    NASAL    I'ASSAGES. 


■       I 


Fig.  24-  Tiirck's  tongue-depressor. 


Kig.  25.^ — Davidson's  atomizers,  to  be  used  l)y  compressed  air 
or  hand-bulb. 


Fig.  26. — Burgess's  metal-tube  atomizers:    straight,  up,  and  down. 


IN'STRt'MRN'TS    AVP    THKIK    fSKS. 


'2-3 


Fig.  2r)«.-  liosworth'a  afomizor. 


Comprpssod-air  iipparatus. 


2.  Insufflators,  or  powder-blowers,  of  wliicli  also  there  are  uiany 
in  the  market  (FigfJ.  ^8,  2S«,  281),  and  2Hr).  'I'he  name  is  indicative 
of  their  utility.     Also  post-nasal  8yrinp;es. 


I"   .;m 


24 


DISEASES   OF   THF    NASAL   PASSAGES. 


i 

H"! 


^'^' 


Fig.  28. — Powder-blower  with  inoutli-piece  and  lube. 


Fig.  28«. — Powder-blower  with  bulb. 


Fig.  28ft. — Powder-blower  with  tubing  and  bulb. 


Fig.  28('. — Powder-blower  with  scoop. 


3.  Nasal  saws,  of  wliicli  l?os\vorth's  is  the  model  upon  which 
most  of  the  others  are  founded  (Figs.  2J>  and  30).     They  are  used 


INSTRUMENTS   AND   TIIKIU    USES.  gg 

to  remove  segments  or  sections  from  tlie  nas-,1  senfnm      t?    »    • 


Fig.  29.^-]5os\vortl,'8  nasal  sau.. 


Fig.  SO.-Alials  reversible  saw. 


Fig.  31.— Hartniann's  nasal  chisels 


!|J; 


ill 


2G 


DISEASES   OF   THE   NASAL  PASSAGES. 


Fig.  32.— Freeman's  drill. 


Fig.  33. — Bosworth's  niisal  polypus-snare. 


Fig.  34. — Snjoiis's  nasal  polypus-snare. 


5.  Cold-wire  snares  of  many  varieties  are  exceedingly  valuable 
for  removal  of  polypi,  as  well  as  other  growths  within  the  nasal 
cavities  (Figs.  33  to  36). 


INSTRUSfENTS   AXD   TIIKIR    USES. 


27 


Fig.  35.-nall's  luisal  polj 


pus  snare. 


Fig.  36.-Doneh's  na.sal  polypua-snar 


Fig.  37.-UniversaI  cautery  and  snare-handle,  ^^i 


th  cannula  and  snare. 


:% 


ii 


ble 
isal 


Fig.  38.— Cautory-eleetrodoa. 


6.  The  galvanoca-utery-siiare  is  also  receivofl  ulH,  u 
Quartpf'?  ^FJfr    •?7\    +1        i  ,  ittcnoa  with  iavor  in  some 


i'j 


V'S 


DISKASKS    Ol'    TIIH    NASAf,    I'ASSA(iKS. 


l-'or  the  latter,  ("annaiilt  Jones's  spokesliavc,  with  various  mollifica- 
tions of  it,  has  hocn  received  with  marked  favor  in  iMiglaiid,  wliile 
on  this  continent  it  has  nsuallv  not  Ix'cn  Vidiicd  so  IiiLxhlv  (I'Il:.   II). 


E     D 


m 


B 


l-'ig.  31). — Xa*il  huiTH. 


Q 

I'ig.  40.  -Nusal  tn'pliiiK'ss.     (Cuiiisa.) 


]''i;^.  41.- Hcri'iTs  (1)  ami  XicliolsV  cii   sjidkcsliavi  s. 


'J'o  the  above  might  be  added  punches  and  curettes,  curved  scis- 
sors and  knives,  forceps  and  clamp.s,  a?  well  as  other  instruments  spe- 


AMKUIOlt    UlllNOSCOI'V 


'J!» 


ciiiDy  (lovi.-('(l  I'or  uso  in  partiiiilnr  cnscs.     Nasal  burrs  for  antral  as 
well  as  sL']ital  uuil:  tiiav  also  he  inciilioiicd  ( l'"i>.'.  <V,i). 

Am  icitiou  J»iHN()sc(H'Y. 

The  view  oliiaiiit'd  liy  means  of  the  I'tiinoscnjio,  inehulin^'  as  it 
lines,  tlu'  liead-niiri'or  iVl'^.  T).  llie  relleeted  liiilil,  and  lln'  nasal  >|ieiu- 
liiiii  ( Fi,u'.  1'.')  i-  iiniy  liniiled,  when  eonlined  to  one  pnsilion;  init  l)y 
niiivinix  tlie  iiead  in  dilfeieut  direelions,  a  ,ixreater  part  (d'  tlit.'  na.-al 
(•avity  can  l)e  Krought  siiceessively  into  view.  15y  lool<in^  directly 
in.  tlie  iloiii'  nf  tlie  nn^e  ;ind   the  infei'ior  turbinated,  as  well   as  the 


Kifr.  42.-  Anlcrior  rliinoseoiiy,  ]Misitio!i  of  the  licad   for  inspoctinrr  tlie  wiill 
of  the  pliarynx  tlu'ou<,'h  the  nasal  iiassagcs.     (After  Bosworlh.) 


■if. 


ICIS- 

pe- 


liiwer  ]iart  of  the  M'ptnni,  can  he  seen.  The  septum  is  very  rarely 
perfectly  central  in  ]iosition,  being  deiiected  to  one  side  cv  the  other. 
In  these  cases  the  whole  length  of  the  inferior  turbinated  can  fre- 
(juently  be  seen,  as  well  as  the  post-])haryngeal  wall,  tlirough  the 
wider  passage:  and  if  the  ])erson  e.xaniined  he  reciuested  to  count 
],  2,  3,  the  movements  (d'  the  palate  can  also  ])0  distinctly  observed 
through  the  inferior  meatus  (Fig.  4'^). 

When,,  owing  to  the  turgid  condition  of  the  mucous  membrane 
the  passages  are  too  narrow  to  admit  of  examination,  this  can  always 
be  aided  ])y  spraying  the  nasal  fossa^  with  a  l-])er-cent.  solution  of 
cocaine.     In  a  few  imunents  its  astringent  ell'ect  upon  the  mucous 


30 


DISEASES   OP   THE    NASAL    PASSAGES. 


membrane  drives  away  the  blood,  and,  shrinking  the  tissues,  a  better 
view  can  be  obtained. 

In  the  normal  state  the  middle  and  inferior  turbinateds  and 
septum  are  of  a  pinkish  Inie,  while  the  roof  of  the  nose  and  the 
superior  turbinateds  are  yellowish  pink. 


Fi{r.  4.3.  "  rosUMior  rliinosropie  imaj^e.     (After  Bishop.) 


POSTEUIOU   KlIINOSCOl'Y. 

To  accomplish  this,  the  head-mirror,  rcllccted  light,  tongue-de- 
pressor, and  post-rhinal  mirror  are  always  required;  and  sometimes 
the  palate-retractor  also  (Fig.  18).  Fig.  43  illustrates  the  method  of 
taking  a  view.  Before  entering  the  throat-mirror  it  is  first  gently 
heated  to  a  blood-temperature  over  a  gass-jet  or  spirit-lamp,  to  avoid 
the  condensation  of  moisture  upon  its  surface.    Care  should  be  taken. 


rOSTKUIOU    IMIINOSCOl'Y. 


31 


after  clcpixvssing  tlie  toiiyiu',  not  to  touch  the  soil  partrf  while  passing 
in  the  instrument. 

'J'o  ohtain  a  good  view  of  the  ])ostcrior  naros  and  vault  of  the 
])harynx  it  is  always  nooossary  that  the  jialatc  .-Imulil  hang  straight 
down.  Jiy  a  little  training  this  can  usually  l)c  iiccnniplislied,  alliiough 
on  first  ell'orts  the  patient  is  very  lii<ely  to  relraet  the  palate  against 
the  post-pharyngeal  wall,  thus  circctually  cutiiiig  oil'  all  view  of  the 
vault  ahove.  liy  directing  the  patient  to  hreathe  through  his  nose 
the  desired  result  may  sometimes  he  ohtained.  (Jf  course,  when  the 
mouth  is  opened  and  the  tongue  held  down  liy  a  depressor,  it  is  im- 
j)ossihle  to  l)reathe  alone  through  the  nose;  but  the  attempt  drops 
the  palate  and  gives  the  reijuired  view. 

This  method  failing,  a  solution  of  cocaine  applied  to  the  palate 
may  remove  irritation  and  produce  the  desired  result.  At  all  events, 
it  will  enable  a  retractor  to  be  applied,  and,  the  velum  being  drawn 
forward,  a  vision  is  obtained. 

In  the  little  post-rhinal  mirror  we  first  have  the  upper  surface 
of  the  soft  palate,  then  the  posterior  nares,  with  the  dividing  septum; 
to  the  two  sides,  the  mouths  of  the  Kustacliian  tubes  and  the  lateral 
walls  of  the  naso-pharynx;  above  the  vault,  and  behind  the  post- 
pharyngeal wall,  over  the  two  latter  we  may  have  the  pharyngeal  ton- 
sil, or,  as  it  is  usually  called  when  in  an  hypertrophied  condition,  the 
adenoids.  Between  the  post-])haryngcal  wall,  on  each  side,  and  the 
mouth  of  the  Eustachian  tube,  is  the  fossa  of  Rosenmiiller. 

All  these  parts  cannot  be  seen  at  once;  and  it  will  require  a 
little  care  and  patience,  both  on  the  part  of  the  observer  and  the 
observed,  with  different  adjustments  of  the  instrument,  to  obtain  an 
entire  view.  The  color  of  the  vault  is  often  a  dark  pink,  witii  lighter 
hue  at  the  sides  and  lower  portions,  while  the  posterior  nares  are 
inclined  to  be  a  yellowish  pink. 


li 


DJSKASKS  OF  TUP]  NOSK. 


CilAlTIlK  1\'. 


ACUTE  RHINITIS. 


'I'liis  is  ;iii  iU  lite  iiitliiiiiiualion  ol'  llic  iiiuimjUs  iiuMuhrimo  ol'  the 
iiiisal  |ia??n2foy.  It  usually  allV't'ts  both  sides  aliko  and  is  attoiidod  1)V 
i>oiTza  or  dist'liarizc  Froquontly  the  iuilaiuniatnry  aclidii  extends  to 
the  jiharynx:    and  soineiiines.  thouiih  unt  very  ol'teu.  to  the  var 


lOU?: 


accessory  vi\\  liie: 


and 


lu'  lacrvnial  ( 


Uiet. 


Pathology. — The  coninieiuenient  of  the  disease  is  the  period  of 
con,i:!'estion,  with  arrest  (>•'  secretion,  and  is  common,  during  the  lirst 
stau'c.  til  all  inllanimalions  of  nnicous  mcnihrane.  This  is  followed 
hv  transu(hition  from  the  uorsied  venous  sinuses  and  increased  seere- 


lidii  of  mucus  from  the  glandular  structures, 


Tl 


lesc 


her  urae 


on  the  exfoliative  processes  of  the  niGmhrane,  and  leucocytes,  as  widl 
as  epithelial  cells,  are  thi'own  off  in  vast  numhers.  ju'oducing  niuio- 


lundent  discharae  durimi'  t 


le  la 


iter  staii'c  of  the  disease 


Etiology. — The  most  common  cause  i-;  exposiire  to  cold.  This 
is  particularly  the  lase  with  susceptible  ])ersons.  In  these  the  su(hlen 
impression  of  a  fall  in  temperature  seems  to  paralyze  the  vasonuitcn* 
lu'rves  of  the  naso-mueosa:  and,  the  control  of  the  capillary  circula- 
tion beiuLT  lost,  the  nu'ndtranes  become  congc-^ted.  The  extent  to 
which  this  congestion  occurs  before  the  inhibilnry  power  is  restored 
wiiuld  imlicate  the  severity  of  the  disease,  in  some  casi'-:  acute  rhinitis 
is  caused  by  exposure  to  acrid  vapors  and  irritants  of  one  form  or 
another;  while  in  not  a  few  instances  it  is  primarily  due  to  the  pr^- 
existcMice  of  chronic  rhinal  disease.  It  is  also  one  of  the  early  indica- 
tions of  certain  of  the  exanthemata,  particularly  in  the  case  of  measlo?. 
Acute  rhinitis  is  more  prevalent  among  children  than  nnumg  adults. 
Wagner  believes  that  it  is  often  produced  by  migraiions  of  micro- 
organisms from  diseased  tonsils  into  the  nasal  cavities. 

Syinptoiiiatology. — 'i'lie  first  symiiiom  is  nsually  that  of  dryness 


ACU'"1-:    HHINITIS. 


X\ 


of  the  nostril?,  at'cumpauiod  liy  iiioie  or  loss  frontal  '■  pi\ision  and 
sneezing.  There  may  he  ehilliness,  lassitude,  and  slight  I  '/file  action. 
The  tingling  si'nsation  within  the  nostrils  is  (jnickly  followed  hy  sero- 
mucous  discharge.  The  llux  may  he  serous  at  lirst,  then  sero-mucous, 
and  finally  muco-pus  hefore  the  discharge  ceases.  Tsually  a  certain 
amount  of  febrile  action  takes  place. 

If  the  frontal  sinuses  are  affected,  frontal  oppression  and  head- 
ache are  the  result,  wliile  the  extension  to  the  luistachian  tubes  and 
pharynx  render  syinpt(uns  in  connection  with  these  organs  apparent. 
Irritation  of  the  coiijiiiuiiva,  with  discharge  of  tears  over  the  cheek, 
would  indicate  that  tlu'  hurymal  duct  was  sutl'cring  from  tein[)orary 
occlusion. 

Sometimes  the  nasal  stenosis  is  very  distressing,  necessitating 
oral  breathing.  I'Lxcoriations  of  the  lips  and  al.T,  by  the  discharge  of 
acrid  secretions,  are  likewise  often  jiroductive  of  much  discomfort. 

The  sense  of  snu'll  may  also  be  alVeeted  during  the  severity  of 
the  attack. 

Diagnosis. — Tiie  group  of  sym])toms  descril)ed  are  so  character- 
istic llial  diagnosis  should  l)e  easy.  The  mucous  meml)rane  is  at  first 
>\vellcd  ami  red;  then  bathed  in  serum;  and  gradually,  as  tlie  color 
becomes  lighter,  muco-pus  takes  its  place.  'I'be  jwistcrinr  clioana^, 
examined  by  the  rliinoscnpe.  reveal  the  niidille  and  inferior  tnr- 
binateds  swelleil,  l>athcd  in  disciiarge,  and  lu-aclically  tilling  up  the 
nares.  Other  mucous  membranes  involved  in  tlie  intlammalory  action 
all  jiresent  a  similar  pink  and  swelled  condition. 

Prognosis.- — Kavoralile  in  a  large  majority  of  cases.  It  involves 
no  danger  to  life,  and  usually  disaj^pears  in  about  a  week.  '^Fhe  real 
danger  lies  in  allowing  colds  to  f(dlnw  each  other  in  such  quick  suc- 
crssicm  as  to  prevent  the  nasal  mucosa  from  resuming  its  normal 
'one.  IVrmewan  and  Carter  have  also  reci'utly  drawn  attention  to 
the  possibility  of  severe  systemic'  infection  neiuLT  induced  liy  ibis 
disease,  cases  being  rcporteil  in  which  |)i'(d(>i \L;ed  illtn.-s  and  continued 
fever,  otherwise  unaccountable,  were  entirely  removed  by  antiseptic 
intranasal  treaiment. 

Prophylaxis. — To  tb.ose  inclined  to  the  disease  regular  habits  of 
life  are  impiu-tanf.  Daily  cold  bathing  either  by  plunge  or  sponge, 
when  followed  by  promiit  reaction,  is  an  important  ]>reventive. 
Clothing  shoidd  be  comfortable  and  equally  dividcfl  over  the  body. 

Heavy  neck  wrappings  are  always  ol)jectionable.  Heavy  furs 
worn  bv  the  ladies  while  callimr  and  left  on  in  hot  rooms  often  have 


:■! 


u 


34 


DISEASES    OF    TUE   NASAL    PASSAGES 


the  effect  of  producing  cold  on  returning  to  the  street.  Wearing  of 
wet  garments,  which  tlie  exigencies  of  weather  or  occupation  so  fre- 
quently render  necessary  for  the  time,  will  rarely  during  active  exer- 
cise produce  injurious  effects,  but  it  is  the  continued  wearing  after 
the  exercise  is  over  that  does  the  harm.  In  short,  if  people  would 
systematically  use  good  common  sense  in  their  daily  walk  of  life,  the 
colds  from  which  so  many  people  suffer  would  be  very  much  rarer 
than  they  are. 

Treatment. — ISTothing  seems  to  check  the  general  feeling  of 
malaise,  attendant  upon  acute  rhinitis,  so  quickly  as  quinine  in  ^7^- 
gramme  doses.  1  prefer  to  give  it  in  capsule  form,  repeating  the  dose 
each  morning  while  the  disease  lasts.  In  strong  vigorous  adults  a 
gramme  might  bo  given  to  commence  with,  taking  the  smaller  amount 
after  the  first  day  or  two.  In  young  children  Y^  or  ^/g  gramme,  ac- 
cording to  age  and  bodily  habits. 

A  saline  cathartic  is  al.-;o  beneficial;  and  the  feet  put  in  hot  water 
at  bed-time,  followed  by  a  stimulating  drink  of  ginger-tea  or  hot 
lemonade.  The  object  aimed  at  is  diaphoresis  and  restoration  of  the 
nf.tural  equilibrium  of  the  whole  body.  If  there  is  unrest  and  wake- 
fulness, with  flushed  face,  acetanilid  in  V^-gramme  dcses  might  be 
repeated  once  or  twice  during  the  night-time.  For  the  same  purpose 
minute  doses  of  morphia  and  atropia  in  tal)let  form  arj  often  given; 
the  combination  has  the  advantage  of  the  astringent  effect  of  the 
atropia  upon  the  mucous  membrane: — 

1.     R  Atropia  aulph |0013 

ilorph.  sulph |0(i5 

M.     Fiat  in  pil.  x  dividenda. 

Sig. :    One  to  be  taken  every  four  or  six  hours  if  required. 


For  Local  'Treatment. — 

2.     1}  Menthol    |0 

Alholonc    001 

M.     Sig. :    To  be  used  with  an  atomizer  to  tlie  nostrils  several 
times  a  day. 

1.  H  Atropia  sulph gr.  Vbo. 

Morphia  sulph R"".  j. 

AT.     Fiat  in  ])\\.  x  dividenda. 

2.  1\  Menthol  gr.  x. 

Albolene    Sij. 

M. 


ACUTE   RUINITIS.  33 

Or 

1.     H  Thymol     1 12 

Menthol    \:i 

Albolene tio'j 

M.     Sig. :    To  be  used  with  an  atomizer  to  the  mintrils  several 
times  a  day. 

Eitlier  of  these  will  be  found  an  excellent  remedy  in  this  disease. 

Bishop,  in  his  recent  work  on  "Kar,  Nose,  and  Throat,"  strongly 
recommends  3  per  cent,  of  camphor-menthol  in  lavolin  as  a  spray 
in  acute  rhinitis.  It  has  a  similar  action  upon  the  inilamed  mucosa 
to  the  ones  just  referred  to. 

Lennox  Browne,  in  the  new  edition  of  his  valuable  book  on 
"Diseases  of  tlie  Xose  and  Throat,"  speaks  emphatically  of  the  value 
of  menthol  in  the  treatment  of  diseases  of  these  organs.  Speaking 
of  this  "remarkable  drug,"  he  says:  "1.  It  stimulates  to  contraction 
the  capillary  blood-vessels  of  the  passages  of  the  nose  and  throat, 
always  dilated  in  the  early  stages  of  the  head-cold  and  influenza.  2. 
It  arrests  sneezing  and  rhinal  How.  3.  It  relieves  pain  and  fullness 
of  the  head  by  its  pain-killing  properties.  4.  It  is  powerfully  germi- 
cide and  antiseptic." 

All  these  statements,  with  the  exception  of  the  one  referring  to 
sneezing,  I  have  agreed  with  for  years.  The  sternutatory  effort  is 
frequently  produced  by  the  first  api)lici  ns  of  the  menthol-spray 
to  the  nose;  but  the  mucous  membrane  soon  becomes  accustomed  to 
the  slight  irritation,  and  subsequent  applications  will  be  borne  with- 
out difficulty. 

When  the  symptoms  show  tardiness  in  abating,  recovery  may 
often  be  hastened  by  using  stronger  solutions  of  the  stearoptenc-!  in 
the  hydrocarbon  menstruum.  For  instance,  the  menthol  mnv  be 
doubled  or  tripled  to  the  same  ijuaiitity  of  albolene,  mid  the  ame 
may  be  said  of  thymol.  In  this  case,  however,  they  sliould  be  inhaled 
directly  into  the  mouth  from  the  atomizer,  and,  the  mouth  being 
dosed,  exhaled  through  the  nofic. 

When  there  is  much  nasal  stenosis,  there  is  sninetinies  a  teiii|iia- 
tion  to  use  cocaine,  owing  to  its  ])o\ver  as  an  astringent  in  producing 
immediate  relief.     It  is  unwise,  however,  ever  to  place  this  remedy 

1.     IJ  Thymol    pr.  ij. 

I\Ien1  liol     trr.  v. 

Albolene    5ij. 

M. 

3 


36 


DISEASES   OF   THE   XASAL   I'ASSAfiES. 


in  the  paliont's  hands.  The  relief  it  afrords  is  only  temporary,  and 
the  more  frequently  it  is  used,  tlie  more  rapidly  does  reaction  take 
jilace,  with  return  of  the  swelling.  The  danger  of  forming  the  co- 
caine-hahit  makes  it  imperative  to  confine  the  use  of  this  drug  to  the 
doctor's  olTice. 

After  the  vascular  ])letliora  has  passed  away  and  the  exudation 
diminished  Bosworth  rccummends  tlie  application  of  chromic  acid 
to  the  still  swelled  memliraiie.  After  coeainization  he  apjilios  minute 
crystals  of  tlie  acid  to  the  promiiuuit  portions  of  the  inferior  turbi- 
nateds,  with  the  view  of  pinning  down  tiie  parts  and  so  securing  con- 
traction. AVherever  I  have  fouiul  cautery  treatment  necessary,  it 
has  always  been  in  ca>es  in  which  some  previously  existing  hyper- 
trophy denunuled  the  operative  treatnu-nt. 

Dry  lieat  api)licd  to  the  forehead  is  sometimes  of  benefit  in  the 
later  stages,  relieving  tlie  frontal  headache  ami  taking  away  the  full- 
ness wliicli  so  often  is  feU  over  the  root  of  the  nose. 


ClIAPTKK  V. 


(TrHOXFr  HinxiTis. 


'J' 1 1 


IS  i>  a  chrniiic   intljiinination  (>(  the  na>al   imicnsa  licarinir  a 


direct,  relation  to  the  aeiite  disease.  Some  oliservers  lielieve  it  to  he 
the  cause  of  the  oft-repeated  occurrenee.s  of  the  hitter,  while  others 
look  upon  it  as  the  elTect.  The  last  mentioned  is  prohal)ly  nearer  the 
truth.  The  entire  mucous  membrane  nuiy  he  involved,  and  tlie  dis- 
ease may  extend  to  the  iMistaehian  tul)es,  the  lacrymal  ducts,  and,  as 
in  the  acute  ilisease,  to  the  accessory  sinuses. 

Pathology. — The  mucous  memhrane  is  thickened  and  puffy, 
while  tiie  venous  sinuses  are  chronically  relaxed.  Interstitial  infil- 
tration is  the  result,  hut  of  a  changeahlc  character.  Freciuently  will 
one  nasal  fossa  he  affected,  closin<^-  it  sulhciently  hy  cedema  to  pro- 
duce complete  nasal  stenosis,  while  fin-  the  time  the  other  is  free 
enou<rh  to  carry  on  respiration.  Lyiug  for  a  short  period  on  the 
open  side  will  reverse  the  condition,  simply  hy  hydrostatic  ijravita- 
tion.  Hydrorrhnea  from  the  veiuius  sinuses,  together  with  the  dis- 
charge of  leucocytes  and  pus-cells  from  the  chronically-irritated 
glands,  becomes  a  leading  feature. 

Etiology. — Ciiiiliniied  exposuic  to  inclemencies  of  the  weather 
— with  insudicieiit  clolhiug.  wet  feet,  etc.,  ])roducing  oft-repeated 
colds— is  a  frei|Ui'iit  cause.  Inhalation  of  irritating  dust  and  gases, 
during  ordinary  occupation,  when  prolonged,  will  induce  the  disease. 
The  presence  of  a  strumous  diathesis  may  be  a  predisposing  cause; 
as  also  may  be  lh(>  jircsence  of  slriictnral  lesions  and  hy[)ertrophies. 

Symptomatology. — The  most  prominent  symptom  is  a  constant 
nasal  discharge,  chiefly  of  a  muco-jiurulent  character,  whicli  induces 
oft-repeated  efforts  at  blowing  and  hawking.  In  aggravated  cases  the 
nares  are  filled  with  a  pasty,  yellow  matter;  and  the  constant  efforts 
to  void  the  discharg(\,  in  some  cases,  produce  swelling  and  redness  of 
the  nose,  as  well  as  eczema  or  ulceration  of  the  anterior  nares.  Owing 
to  the  limited  proportion  of  serum  exuded,  the  secretion  often  be- 
comes dry,  resulting  in  crust-fornuition  about  the  nostrils.  To 
liberate  thi.s,  j)icking  is  resorted  to,  with  gradual  destruction  of  the 

(37) 


illi 


38 


DISEASKS    OF   THE    NASAL    I'ASSAUES. 


il 


I  "^ 


1§ 


mucous  nionibrane;  and,  in  some  cases,  the  septal  cartilage  eventu- 
ally becomes  perforated  by  this  digital  irritation.  The  disease  occurs 
most  frequently  between  childhood  and  early  maturity. 

Diagnosis. — There  is  sometimes  a  nice  distinction  to  be  made  be- 
tween chronic  rhinitis  and  Jiosworth's  purulent  rhinitis  of  children. 
In  the  former  the  disease  may  occur  any  time  after  early  childhood, 
but  rarely  during  that  period,  while  in  the  latter  it  always  occurs 
during  early  life.  In  the  former  there  is  less  purulent  discharge 
than  in  the  latter,  while,  owing  to  the  shorter  period  of  its  exist- 
ence, there  is  less  likelihood  of  its  culminating  in  atrophy.  The 
diagnosis  between  this  and  hypertrophic  rhinitis  is  more  easily  made. 
The  application  of  a  4-per-cent.  solution  of  cocaine  for  the  time 
will  shrink  away  the  infiltration  of  chronic  disease,  which  it  cannot 
do  with  the  enlargements  arising  from  hypertrophy.  On  the  other 
hand,  when  of  long  duration,  it  may  resemble  and  even  be  the 
initiatory  stage  of  atrophic  rhinitis. 

Prognosis. — In  the  region  of  the  great  lakes  of  this  continent 
chronic  rhinitis  is  very  prevalent,  owing  to  the  humidity  of  the  at- 
mosphere and  the  variability  of  temperature.  As  these  cannot  be 
avoided,  the  prognosis  as  to  permanent  result  is  not  very  encouraging. 
If  proper  means  are  adopted,  however,  a  cure  can  be  accomplished, 
though  the  tendency  to  return  may  still  exist.  When  long  continued, 
the  disease  is  likely  to  culminate  in  clironic  hypertrophic  rhinitis. 
Consequently  a  guarded  prognosis  as  to  ultimate  results  should  always 
be  given. 

Treatment. — Regulation  of  the  pmnce  vice  and  toning  up  the 
general  system  are  in  many  cases  necessary  and  can  be  done  on  the 
principles  of  general  medicine. 

Locally,  the  nasal  ])assages  will  require  systematic  cleansing.  For 
tliis,  alkaline  sprays  will  be  required;  and,  of  these,  what  is  called 
Dobell's  may  be  considered  the  best  type.  All  modern  English 
writers  on  disease  of  nose  and  throat  acknowledge  the  utility  of 
DobcU's  solution,  and  give  credit  to  Dobell  for  introducing  it  to  the 
world,  yet  scarcely  two  of  them  agree  upon  its  formula.  I  have  be- 
fore me  the  most  recent  works  of  Sajous,  Bosworth,  and  Bishop; 
and  in  giving  ihe  formula  of  Dobell's  solution,  while  they  all  agree 
as  to  ingredients,  they  all  differ  as  to  quantities.  Here,  I  think,  lies 
the  intrinsic  value  of  the  preparation  as  a  type,  the  combination  re- 
maining intact,  while  the  proportions  are  varied,  according  to  the 
judgment  of  the  physician  in  charge. 


CHRONIC   RHINITIS. 


39 


(or 


sh 

of 

Ihe 


lee 
les 
je- 
ll e 


My  own  rendering  of  Dobell's  solution  is  the  following: — 

1.     R   Sodii  bicaili 21 

I 
Sodii  bibor 2 

Aeidi  earbol 1 

Cilyei'iin     15 

Aquuiii   ad  250 

;M.     Sig.:    To  be  used  with  llif  atoinizpr  to  thr  iioso,  as  re- 
quired, several  times  a  day. 

The  advantage  of  this  and  similar  preparations,  used  freely  as 
sprays  to  the  nose,  is  that  they  are  l)oth  alkaline  and  disinfectant, 
acting  as  solvents  to  the  muco-purulent  secretions,  which  require  to 
be  removed. 

After  clean.sing,  oleaginous  sprays  are  indicated  for  their  sooth- 
ing, protective  influence  upon  the  mucous  nu>ml)rane.  The  oil  used 
as  a  menstruum  slimild  be  one  of  the  recently-discovered  hydrocarbons, 
as  from  their  mineral  origin  and  chemical  composition  they  can  never 
become  foul  or  rancid.  It  matters  not  whether  it  be  liquid  vaselin, 
lavolin,  glycolin,  albolene,  or  any  other  of  the  many  that  are  in  the 
market,  so  long  as  it  is  pure,  colorless,  inodorous,  aiul  unirritating; 
but  these  requirements  arc  essential.  The  one  I  have  generally  used 
is  albolene.  The  medicament  dissolved  in  the  oil  should  be  of  a 
slightly  stimulating  and  antiseptic  character.  For  instance,  1  to  2 
per  cent,  of  menthol  in  albolene,  ^/^-peT-ccni.  thymol  in  alliolene,  1 
to  2  per  cent,  of  eucalyptol  in  albolene,  1  per  cent,  of  crcasote  in 
albolene,  or  1  to  2  ])er  cent,  of  camphor-inonthol  in  alljolcne.  The 
first  and  second  of  these  I  have  used  moro  extensively  than  tiie  others, 
the  treatments  being  repeated  from  one  to  three  times  a  day. 

The  treatment  of  atrophic  rhinitis  by  massage,  introduced  several 
years  ago  ])y  Braun,  of  Italy,  induced  me  to  try  it  also  in  simple 
chronic  rhinitis.  He  used  probes  with  olive-shaped  tips;  and.  passing 
one  into  the  nostril,  guided  by  iiead-mirmr  aiul  nasal  speculum, 
would,  by  tremulous  pressure  of  the  hand,  ]U'odiico  vibration  over  the 
diseased  tissue.  The  method  T  have  followed,  though  copied  from 
Braun,  has  been  of  a  simpler  nature,  and  would  be  practiced  on  each 
visit  of  the  patient  for  treatment. 


R   Sodii  bicarb frr.  xxx. 

Sodii  bibor ,!-'r.  xxx. 

Aeidi  earbol ptt.  xv. 

Cilycerin     3iv. 

Aqiiani    ad  Jviij. 

M. 


m 


10 


])lSi;.\SKS    OF    THE    NASAL    PASSAOKS. 


Tlic  end  of  an  ordinary  nasal  cotton-carrier  would  l)e  wrapped 
firmly  with  a  small  })ledget  of  cotton,  the  thickness  of  the  temporary 
tij)  beintf  made  to  accord  with  the  width  of  the  crevice  in  the  nasal 
])assa<j:c  to  which  it  was  to  he  applied.  Then  the  tip  would  lie  dipped 
in  alholene,  and.  after  insertion  into  the  nostril,  manij)ulated  in 
accordance  wilii  Hraun's  nicthod.  \>\  })roper  care,  coml)ined  with 
gentleness  of  touch,  massage  of  the  whole  mucous  membrane  can  he 
done  without  the  use  of  cocaine,  and  with  very  little  discomfort  to  the 
patient.  With  eacli  ajiplicalion  the  used  pledget  is  stripped  olf  and  a 
new  one  aj)j)lied  almost  in  a  moment — three  or  four  being  required 
for  each  nostril  at  one  sitting.  After  massage  a  spray  of  alholene  or 
sinular  oil  is  all  that  is  needed. 

]n  a  large  uumber  of  cases  this  treatment  has  been  attended  with 
very  satisfactory  results.  The  usual  ollice-forraula  has  been:  1. 
Cleansing  the  nasal  fossiu  by  a  free  spray  of  DobelTs  solution.  3. 
Massage  of  both  jiassages.  '•>.  Application  of  a  spray  of  alljolene  to 
each,  for  iHUiie-trcatment  the  patient  has  been  instructeil  lo  use 
simple  ch'ansing  sprays,  as  required,  between  the  visits  to  the  ollice 
for  massage — the  latter  being  re])eateil  every  second  or  third  day,  a 
few  treatments  oidy  being  required. 

Of  the  two  methods,  1  have  looked  upon  the  massage  treatment 
as  more  elfectual  than  that  of  simple  medication. 

In  the  posterior  thickening  of  the  septum,  which  so  frequently 
occurs  in  the  chronic  rhinitis  of  adult  life,  we  have  a  combination  of 
oedema  with  epithelial  cell-proliferation.  It  is  usually  bilateral,  ami 
exists  in  the  form  of  a  perpendicular  ridge,  a  little  in  front  and  on 
each  side  of  the  posterior  edge  of  the  vomer.  The  hypertro])liy  is, 
in  some  cases,  so  great  as  to  seriously  interfere  with  the  nasal  breath- 
ing and  to  necessitate  operative  treatment.  This  is  best  done  l)y  the 
galvanocautery.  After  cocainization  the  l)lade  is  passed  into  the  nostril 
and,  guided  by  the  post-rhinoscopic  mirror,  the  membrane  is  freely 
singed.  No  special  after-treatment  is  needed;  and  after  a  week  or 
so,  by  which  time  the  surface  will  have  healed,  the  operation  can 
be  re])eated  if  required. 


CIIAITKU  VI. 


PURULENT  KIILNITIS  01"  (  HILDREX. 

lioswORTii  was  the  first  to  clearly  and  di'Cmitcly  outline  i)iiruleiit 
rliinitis  and  to  place  it  on  the  list  of  representative  nasal  diseases. 
Other  writers  had  spoken  of  it  before,  jtarticidarly  MacKenzie, 
Stoerck,  Fraenkel,  and  Cohen,  but  it  remained  for  ]>oswor(h  to  recog- 
nize its  lull  importance  and  to  intimate  the  position  which  he  believed 
it  to  occupy  in  the  etiology  of  atrophic  rhinitis. 

Pathology. — As  described  by  him,  it  is  a  disease  peculiar  to  the 
earlier  years  of  childhood,  its  prominent  feature  being  tiie  chronic 
discharge  of  purulent  nuilter  from  the  anterior  nares.  This  discharge 
is  purely  local,  and  not  dependent  on  constitutional  diathesis.  In  the 
earlier  stages  there  is  increased  secretion  of  mucus,  with  ra|)iii  ^\c!^- 
(piamation  of  epithelial  cells.  The  discharge  gradually  assumes  a  pu- 
rulent form,  and  after  lasting  a  nuiidicr  of  years  results  in  the  shrink- 
age of  the  turbinated  bodies  and  the  development  of  atrojiiiic  disease. 
In  support  of  this  theory  J3oswortli  says:  "That  in  youth  the  epi- 
thelial structures  are  especially  liable  to  become  the  seat  of  diseased 
action,  whereas  in  adult  life  this  tendency  seems  to  disappear,  and  in 
place  of  it  there  obtains  a  tendency  to  the  involvement  of  the  con- 
nective-tissue structures.  Thus,  in  the  earlier  years  of  life  we  notice 
this  tendency  in  the  development  of  enlarged  tonsils  and  follicular 
disease  of  the  upper  air-tract,  as  well  as  in  the  vulnerability  of  the 
lymphatic  glands,  wliei'i>as,  in  adult  life,  inflammatory  changes  in  the 
mucous  membranes  result  in  true  connective-tissue  hypertrophy." 

Wagner  also  expresses  the  same  opinion  when  he  says:  "During 
childhood  the  skin  and  mucous  membranes  are  more  excitable;  more 
prone  to  disorders  of  the  circulation.  The  function  of  the  lymjihatic 
glands  is  prominent  in  childhood;  the  cpiantity  of  lym])h  is  increased; 
the  lymphatic  glands  at  this  time  have  their  greatest  development." 
Hence  the  tendency  during  childhood  would  appear  to  be  toward 
the  abnormal  development  of  glandular,  adenoid,  and  lymphatic  tis- 
sues in  the  throat  and  naso-pharynx,  and  to  proliferation  and  des- 
quamation of  epithelial  cells  in  the  nose  itself. 

(11) 


n 


48 


DISEASKS   OF   TlIK   NASAL   PA88AOKS. 


Etiology. — Tlie  literature  regarding  the  etiology  is  very  scant; 
but,  as  it  occurb  in  otlicrwise  iicaltliy  and  rugged  children,  struma 
and  hereditary  syphilis  are  not  considered  potent  factors  in  its  pro- 
duction. Bosworth  ascrihcs  taking  cold  from  unhygienic  conditions, 
and  also  neglect  of  the  ordinary  rules  of  health,  as  the  only  assignable 
causes. 

From  my  own  experience,  I  believe  we  frequently  have  more  direct 
causes,  and  that  the  pathological  tendencies  already  referred  to  as 
incidental  to  childhood  are  suflicient  to  produce  the  disease.  In  many 
cases  th*at  I  have  seen  the  purulent  rhinitis  has  been  associated  with 
hypertrophy  of  the  faiicial  and  pharyngeal  tonsils.  These  bodies 
have  been  so  large  as  to  interfere  seriously  with  nasal  respiration. 
In  these  cases  the  adenoid  enlargement  and  the  epithelial  desquama- 
tion ran  side  by  side;  but,  owing  to  tlie  stenosis,  it  was  impossible  for 
the  purulent  discharge  to  make  its  escape.  Like  a  ilowing  well,  it 
ebbed  out  and  over  the  surface,  while  the  retained  discharges  produced 
irritation  and  continued  development,  as  a  consequence.  That  the 
adenoid  enlargement  was  the  real  cause  of  the  purulent  rhinitis 
seemed  verified  by  the  fact  that  the  removal  of  the  tonsils  and  ade- 
noids would  be  followed  by  cessation  of  nasal  discharge  and  restora- 
tion of  normal  breathing.  Some  cases  undoubtedly  do  occur  with- 
out the  co-existence  of  tonsillar  hypertrophy,  but  the  majority  that 
I  have  seen  have,  at  least,  been  associated  with  adenoids.  This  view 
is  borne  out  by  the  experience  of  Lennox  Browne  upon  the  same 
subject. 

Symptomatology. — The  chief  symptom  is  the  continued  discharge 
of  yellow  muco-pus  from  both  nostrils.  During  the  night-time  con- 
siderable quantities  flow  out  aiid  are  deposited  upon  the  pillow.  On 
examining  the  pharynx,  the  V.'ce  discharge,  perhaps  slightly  grayer  in 
color,  may  frequently  be  seen  trickling  down  behind  the  soft  ]ialato, 
the  yellower  color  as  it  exudes  from  the  anterior  nares  being  due  to 
freer  oxidation.  The  blocking  of  the  nostrils  necessitates  mouth- 
breathing,  which  is  still  further  aggravated  when  adenoids  are  present. 

Fcetor  is  of  rare  occurrence,  except  late  in  the  disease,  when  it  is 
gradually  assuming  the  atrophic  form. 

Diagnosis. — The  continued  presence  of  the  anterior  nasal  dis- 
charge is  a  strong  point  in  diagnosis.  Another  one  is  that  it  is  bi- 
lateral and  odorless.  In  scrofula  and  syphilis  the  discharges  are 
offensive  in  odor  and  often  are  bloody,  and  accompanied  by  systemic 
manifestations  indicative  of  the  disease.     The  presence  of  a  foreign 


IMUll.KN T    IIIIIMTIS    OF    CHII-DUEN. 


43 


body  or  rhinolitli  would  1)o  dit^tinfruiplied  hy  being  unilateral  and  the 
discharge  accompanied  by  malodor.  Sometimes  ]iurulent  nasal  dis- 
charges accompany  the  develojimont  of  exantheniatous  diseases;  but 
in  these  cases  the  history  proves  the  relationship,  and  the  unpleasant 
symptoms  are  short  lived. 

Rhinoscopic  examination  anteriorly,  after  the  removal  of  the  dis- 
charge, will  reveal  a  slightly  swelled  and  reddish  condition  of  the 
turbinateds  and  septum,  but  without  ulceration;  while,  posteriorly, 
grayish  or  yellowish-green  mucus  will  be  observed  in  the  naso-pharynx. 

Prognosis. — Without  appropriate  treatment  tlie  prognosis  is  bad. 
There  is  no  danger  to  life,  and  it  is  a  self-limited  disease;  but  the 
limit  extends  over  so  many  years  that  serious  results  of  a  permanent 
character  follow,  unless  the  limit  be  l)roken.  When  adenoids  co- 
exist, they  naturally  comnumce  to  shrink  away  about  the  tenth  or 
twelfth  year;  and  with  the  shrinkage  comes  freer  nasal  breathing 
and  drying  of  the  mucosa.  r>ut  during  the  years  of  the  purulent 
rhinitis  the  epithelial  layer  has  slowly  wasted  away,  and  the  follicles 
and  mucous  glands  and  venous  sinuses  have  all  been  involved  in  the 
shrinkage,  while  the  relief  from  the  adenoid  absorption  has  come  too 
late  to  prevent  the  occurrence  of  the  dreaded  atrophy. 

In  the  early  stages,  however,  before  the  vitality  of  the  mucous 
membrane  has  become  exhausted,  a  hopeful  prognosis  may  be  given, 
provided  proper  treatment  is  instituted  and  carried  out. 

Treatment.— The  first  step  in  treatment  is  to  ascertain  whether 
adenoids  are  present  or  not.  If  present,  even  if  not  very  large,  they 
should  be  at  once  removed;  as  a  limited  ])ost-nasal  swelling,  coupled 
with  the  purulent  inflammatory  cfuidition,  will  ])roduce  severe  steno- 
sis. The  removal  of  these  growths  lias  a  double  cirect:  First,  by 
direct  depletion  of  the  parts  by  the  liaMuorrhage  resulting  from  the 
operation,  and,  second,  by  the  permanent  removal  of  the  obstruction; 
both  of  which  have  the  effect  of  checking  the  purulent  inflammation. 
Consequently  the  su])sequent  treatment  which  I  have  found  most 
effective  has  been  of  the  mildest  character,  sprays  of  albolene  alone, 
or  of  1  per  cent,  of  menthol  in  albolene,  or  Vj  P^i'  cent,  of  thymol 
in  albolene,  two  or  three  times  a  day,  for  a  short  while,  to  the 
nostrils,  being  all  that  has  been  required  to  effect  a  cure. 

In  cases  where  it  is  inopportune  to  operate,  or  in  which  an 
operation  is  not  required,  the  nostrils  should  be  thoroughly  cleansed 
by  the  use  of  a  good  atomizer  several  times  a  day,  using  either  a  mild 
saline  or  alkaline  solution.    Dobell's  solution  to  which  has  been  added 


44  MISKASKS    OK    llli;    NASA  I,    I'ASS  \(i  KS. 

V4  pci'  cent,  of  tliyiiiol  is  an  I'll't'ctivc!  cloniLsiT.  Of  others.  1  per  cent. 
of  chloride'  of  sodiiiiii  in  water,  or  1  per  cent,  of  chlorate  oi  iiota.ssa 
in  water,  will  either  of  them  do  ^.'ood  service,  a  few  drops  of  ^.dycerin 
being  aiUlcd  to  give  softness  to  tiie  soliilidM. 

Tlie  spraying  of  the  nose  siionld  each  time  he  followed  hy  forcible 
blowinir  to  remove  the  pus.  After  this  IJosworth  I'ecommends  spray- 
ing witi:  mild  astringent  solutions  for  the  purpose  of  controlling  cell- 
I)roliferations,  and  he  iu.-luuces  the  following  nuuuig  others: — 

1.  It  (llycciol  laiiiiiii   4' 

Aquiim    ad  UUi 

M. 

2.  U  Arj,'ciil.    iiilnit 12 

Aiiuiiiii     ad  ;((»[ 

M. 

3.  U  Alnniiii-.     |((o 

A(iuam    ad  .'idi 

M. 

Altlu)Ugli  I  have  often  tried  them,  1  have  never  heer  favnrahly 
impressed  by  the  \i>o  of  a(|ueous  sprays  in  this  disease,  ^'oung  chil- 
dren are  exceedingly  averse  to  the  irritation  jtrodnccil  hy  tluMu.  The 
objection  is  frei[uently  so  greai  that  to  secure  tlu'  successful  use  of 
tlie  atomizer  tbe  pbysician  is  obliged  to  apply  it  himself,  wbicli  is 
usually  impracticable,  when  it  reiiuircs  to  he  \\>r(\  more  than  once 
a  day. 

The  sprays  of  bydrocarbons,  on  tbe  other  hand,  arc  so  line  and 
imirrilating  that  they  can  be  borne  by  tbe  child  with  impunity,  and 
the  parents  or  guardians  can  ajtply  them  without  any  ditViculty.  They 
possess  this  advantage,  too,  that  a  single  preparation  will  answer  all 
purposes,  thus  simjdifying  the  treatment.  In  some  cases  sprays  of 
albolene  or  glycolin  alone,  repeated  several  times  a  day,  have  been 
sufTicient,  while  in  others  1  to  2  ))cr  cent,  of  menthol  in  the  bydro- 
o;irbon  and  ^/.,  to  1  per  cent,  of  thymol  in  the  like  menstruum  have 
been  required.  Other  drugs  as  well — as  eucalyptol,  oil  of  caraway, 
creasote,  etc.,  in  small  quantities  in  tbe  neighborhood  of  1  ]ier  cent. 
— could  also  be  used  to  advantage  in  these  only  ajiparently  intractable 
cases.  The  use  of  these  preparations,  however,  do  not  detract  from 
the  importance  of  the  removal  of  obstructive  lesions  when  they  exist. 

1.  B  Glycerole  of  tannin 3i  to  Jj. 

2.  R  Ardent,  nitrat.  t;r.  iii  to  ,?j. 

•').     B  Aluininis   trr.  \  to  Sj. 


,;!  " 


{•ii.\rri:i{  vii. 


iivrKUTiioi'inc  miiMTis. 


This  is  a  rlironic  iiilliiiimiiitinii  of  tin-  iiiiicnii.^  mombrano  of  the 
uusal  passii^ii's  all'cctiiiji  ihii'tly  tliu  turltiiiatL'il  Ijodics  ami  ueeurriiig 
most  i'l'L-iiiU'iitly  during  tlu'  early  years  of  maturity. 

Pathology. — 'l"lic  iiiiicou>  nii'iiilniiiit'  of  the  miiMle  ami  inferior 
turbinatods,  particularly  tlic  latter,  is  tbiekeued  and  eorniyated  (Fig. 
44).     The  snrfafe-epitlicliiiin   is  hypcrtropliicd,  sninetiiiies  extt'iiding 


ii 


IH 


Fiff.  44.      ilv|icrtin|iliy  nf  iniiliilc  mikI   inferior  tnihinals. 
i.\l't<'i-   l!iis\\(i)tli.  I 


in  a  .stratiiied  form  into  the  eoimcctivc-tissiu'  layiT  lieiicatli.  Tbis 
secoml  biyer  is  lil\e\\i>e  eiilargt'd,  owing  to  ])roliferation  of  new  tis- 
snc-elements,  wbieb  freipieiitly  become  fibrous  in  character.  The 
cavernous  sinuses  below,  together  with  all  the  Idood-vessi^ls  of  the 
miicnsa,  may  bcciune  permanently  ililated.  the  glandular  elements 
likewise  being  affected,  the  racemose  glamls  having  increased  in  num- 
bers. With  all  tliis  coud)ined  bypertropby.  there  is  little  epithelial 
desquamation.      In  advanced   stage~  <d'  the  disease  new  connective 

(4.5) 


II 


46 


DISKASlCiS    OK    TlIK    NASAl.    I'ASSAtlKS. 


tissue  is  formed  hy  proliferation  from  the  old  c  >nnective  cells,  produc- 
ing the  want  of  tendency  of  these  hypertrophies  to  undergo  spon- 


Fig.  4r).— Section  of  inf.rior  (iirliiiialid  iLT)  diainetiMs).  o,  Stratified 
ciliated  opitlielium.  b,  (Jlitnds  of  siil)imi(osa.  c.  Sinus  of  erectile  tiaauo. 
d,  irter\.  t',  Vtlii.  f.  ]|y|icitrc])liie(l  (nil)iiintt'(l  Imne.  fAnthor'a  speci- 
men by  Ik'nsley.) 


llYrKIlTROPHlO   imiNITIS. 


47 


taneous  resolution.  In  some  cases  the  hypertrophy  involves  the  tur- 
binal  bone  also,  as  shown  in  microscopical  section  (Fig.  45), 

Of  the  inferior  turbinatcds,  all  parts  are  about  equally  liable  to 
enlargement,  with  possibly  a  predominance  of  tendency  in  the  pos- 
terior end  (Fig.  46),  while  in  the  middle  turbinated  it  is  the  anterior 
end  that  is  usually  involved.  The  Figs.  4Ga  and  4G&  give  histological 
sections  of  portions  of  tlie  anterior  and  posterior  ends  of  the  inferior 
turbinated. 

Etiology. — Anything  which  will  produce  continuous  partial  ste- 
nosis in  the  anterior  end  of  one  nostril  has  a  tendency  to  produce 


m 


Fig.  40. — Large  niassos  of  hypertrophied  niembnane  on  the  posterior 
termination  of  the  lower  turbinated  bones,  more  or  less  completely  filling 
the  posterior  narcs.     (After  Uosworth.) 


turbinai  li\])ertrophy  on  the  same  side.  A  little  consideration  will 
make  the  I'cnson  of  tliis  iilaiu.  Inspiration  of  air  ihroiiiih  the  nar- 
rowed inlet  iiiiMiediately  produces  rarefaction  Ixliiud  the  obstruction, 
owing  to  the  forcible  manner  ii!  wliich  the  air  i.s  drawn  through  the 
passage.  This  rarefaftiou  means  diminished  atniospher.c  pressure, 
repeated  with  each  inspiration,  and,  acting  on  the  soft  tissues  of  the 
turbinatcds,  it  produces  a  tendency  to  abnonnal  congestion. 

Consequently  any  malfmination  of  tlie  front  end  of  the  septum, 
whether  of  traumatic  origin  or  not,  wbich  has  the  olTect  of  making 
one  nasal  passage  materially  narrowc  than  the  other,  is  likely  to 
cause  a  gradual,  but  pernumenl,  enlargement  of  the  turbinai  tissues 
behind  it.    If,  on  the  other  band,  the  closure  of  the  passage  from  septal 


48 


DISKASKS    OF    line    ^■A^.V^    PASSAIiKS. 


deformity  is  so  complctL'  ii.<  to  jirodiice  actuiil  stonosis,  there  can  be  no 
hypertrophy  on  tlic  iilTectcd  side;  but  tliere  may  l)e  on  the  opposite 
one,  owing  to  tlio  extra  lalior  ot  inspiration  through  the  single  channel. 


]''ig.  4G</. — Aiitciior  pditidii  of  inferior  tiirliiiial   ('/;.-inch  objective). 
(After  T.ciinox   Brow  no.) 


Fig.  4G6. — Poshrior  |iorlion  of  inferior  turbinal   ( I-incli  objective). 
(After   Lennox  Browne.) 


Narrowing  of  the  anterior  nares  by  displacement  of  the  columnar 
cartilage  may  also  produce  turbinal  hypertrophy  in  the  same  way. 


llVl'KHTKOrillC    RHINITIS. 


•I!) 


There  is  iinotlici'  CfUisc  of  Wua  (lii^ease  which  I  have  not  seen 
mentioned  hy  any  iuilhoi'  upon  the  suhject,  Ijiit  whicli  I  hclievt'  is  not 
by  any  means  infrequent,  and  that  is  the  ]ial)it  which  many  a  molluT 
has  of  always  hiying  lior  eliihl  on  the  same  side  while  sloei)ing.  It  is 
a  well-known  fact,  which  any  observer  can  verify  for  himself,  that 
lyinji'  oil  one  side  will,  in  a  very  few  minutes,  produce  turi^escence  of 
the  turl)inat('ds  of  tiuit  side,  accom|)anied  l»y  comparative  ana'iuia  of 
those  in  the  upper  nasal  cavity.  This  is  simply  the  result  of  gravita- 
tion. The  turbinal  tissues  are  naturally  so  lax  that  the  dependent 
ones,  other  things  being  equal,  are  always  congested  at  the  expense  of 
tliose  fluit  ai'e  above.  l>y  closing  the  lower  nostril  the  upper  one 
will  be  found  to  be  doing  nearly  all  the  breathing,  while  closiin'  of 
the  upper  oiii'  will  reveal  the  fact  that  little  air  passes  through  the 
one  beneath.  Ifeversing  the  position  to  the  oi)])osite  side  will  further 
substantiate  the  same  law. 

The  conse(juence  is  that,  l)y  persistently  placing  tlie  child  on  the 
one  side  while  sleeping,  t!'e  mother  is  continually  pi'oducing  con- 
gestion of  the  same  set  of  turbinateds,  forcing  the  infant  to  do  the 
greater  part  of  its  respiration  through  tlie  upper  nostril.  It  is  only 
reasonable^  to  conclude  that,  in  a  healthy,  rapidly-growing  child,  con- 
tinual hypera'mia  of  one  set  of  turlnnateds  would  lead  to  their  hyper- 
trophy. l)Ut  this  is  not  all;  the  rarefaction  nf  the  air  upon  the  lower 
side  of  the  soft  cartilagiiu)us  septum  of  the  infant,  with  the  full 
pressure  of  fifteen  pounds  to  the  inch  on  the  upper  side,  will  have  a 
tendency  to  slowly,  but  surely,  dellect  it  toward  the  least  resistance, 
thus  jK'rnianently  narrowing  the  nostril  and  tending  to  hypertrophic 
onlargenient. 

(}uite  fre(|UenlIy,  liyperl rophic  rhinivis  owes  its  origin  to  other 
jauses.  Strumous  habit  may  ]iro(luc(^  it.  particularly  when  attended 
by  injudicious  exjiosure.  Sudden  changes  of  temperature  oft  re- 
peated, particularly  when  the  patient  is  unwisely  or  inedlciently 
clothed,  nuiy  also  give  rise  to  it.  Tiong-continued  chronic  rhinitis  may 
also,  in  certain  cases,  culminate  in  hypertrophic  disease. 

Symptomatology. — The  most  ludniimuit  symptom  in  hyper- 
troidiic  rhinitis  is  the  olistnu^tion  to  nasal  resjiiration  ])roduced  by 
the  enlarged  turbinal  tissues.  Together  with  this,  there  will  be  a 
change  in  the  normal  secretion  and  its  reti'iition  to  a  more  or  less 
extent  within  the  nasal  cavity.  The  discharges  are  thicker  and 
more  opiupii'.  owing  to  lessened  exwdation  of  serum  and  increased 
seereticu   of  innco-pus.     The  ditliculty   in   luisal   respiration   and   the 


50 


DISEASES   OF    THE    NASAL    I'ASSAOKS. 


amount  of  discliarge  are  both  variable,  being  controlleil,  to  a  certain 
extent,  by  the  temperature  and  humidity  of  tlie  atmodpliere.  In  warm 
dry  weather  the  nasal  passages  are  freer,  with  less  abnormal  secretion, 
while  in  damp  and  cold  seasons  of  the  year  there  is  greater  swelling, 
increased  stenosis,  and  more  profuse  muco-purulent  discharge.  When 
tins  occurs,  the  pharynx  also  becomes  involved,  becoming  dry  and 
irritable,  on  account  of  the  oral  breathing  which  has  become  necessary. 

Crusts  do  not  form  in  this  disease,  except  occasionally  around  the 
anterior  nares  and  the  front  ends  of  the  inferior  turbinateds.  When 
they  do  occur,  it  is  due  to  the  drying  effect  of  the  atmosphere,  com- 
bined with  deficient  serous  effusion  from  the  affected  membrane. 

There  is  rarely  any  odor  with  this  disease.  When,  however,  the 
dense  secretion  is  retained  among  the  deep  crevices  for  an  unusual 
length  of  time,  mild  putrefaction  may  set  in;  but  the  odor  is  very 
different  from  the  more  offensive  one  of  atrophic  rhinitis. 

The  sense  of  smell  is  often  notably  impaired,  owing  to  occlusion 
of  the  nasal  chambers.  The  voice  becomes  thickened  and  nasal,  while 
impaired  hearing  and  occlusion  of  the  lacrymal  duct  may  occur  as 
results  of  the  disease. 

Headaches  may  arise  from  hypertrophy  of  the  middle  turbinateds, 
and  in  these  cases  the  enlargement  is  likely  to  press  upon  the  se])tum. 

ITay  fever  and  asthma  are  also,  in  some  cases,  attributed  to  it. 

Diagnosis. — For  this,  rliinoscopic  examination  is  necessary. 
Symptoms  may  indicate  in  a  general  way,  but  they  cannot  alone  give 
a  ]>ositive  diagnosis.  On  examination,  the  turbinateds  will  l)e  found 
to  be  more  or  loss  swelled,  and  the  mucous  membrane  covering  them 
of  a  bright-roddish  color.  A  certain  amount  of  muco-pus  will  always 
be  present.  The  lower  turbiiuited  is  usually  the  most  swelled,  some- 
times almost  filling  the  inferior  meatus.  The  anterior  end  is  the 
reddest,  the  color  gradually  assuming  a  grayer  hue  toward  the  middle 
and  ])osteri()r  end  of  the  bo.ly.  Tlie  enlargement  of  the  turl)inateds 
is  Uf^ually  somewhat  irregular,  nodules  often  standing  out  jiromi- 
ncntly  in  dilTcrent  parts.  Occasioiuilly  the  hypertrophic  masses  have 
become  united  lo  the  septum  by  bridges  or  syuecliiie  of  fibrous  tissue. 
This  is  more  likely  to  occur  in  hypertrophy  of  the  middle  turbinated 
than  of  the  inferior,  owing  to  its  closer  proximity  to  the  septum  and 
the  greater  tendency  to  enlargement  of  the  anterior  end. 

The  nasal  speculum,  aided  by  reflected  light  and  the  use  of 
the  head-mirror,  is  always  essential  lo  examination.  In  posterior 
hypertrophies  the  post-rhinal  mirror  reveals  the  condition,  the  end 


uyi'Ektkoi'Hic  uiiimtis.  51 

of  the  inferior  turl)inated  assuming  a  corrugated,  swcllctl  appearance, 
almost  like  a  wliitc  strawberry,  and  in  some  cases  entirely  tilling  the 
posterior  clioana  (I'ig.  -KJ). 

In  a  few  instances  the  posterior  liypertrojiliy  lias  a  reddish  hue. 

Sometimes  an  (edematous  congestion,  as  in  rhinitis  auleniatosa, 
might  he  mistaken  for  a  true  hypertrophy;  hut  the  application  of  a 
r)-j»er-cent.  solution  of  cocaine  will  soon  remove  the  (loul)t.  In  either 
ease  the  swelling  will  be  reduced;  but  in  true  hypertrophy  the  re- 
♦luction  will  be  limited,  the  abnormal  librous  tissue  of  the  body  still 
leaving  it  in  a  swelled  condition,  while,  in  the  other,  the  cocaine  will 
soon  shrink  the  (edematous  tissue  down  to  even  a  subnormal  state. 

Prognosis. — Under  pro])er  surgical  treatment,  wlien  the  disease  is 
•  me  ol'  simple  hypertrophy,  the  prognosis  is  always  favorable.  Without 
surgical  treatment  it  is  a  prolonged  disease,  the  ultimate  result  in 
many  ca.<es  being  exceedingly  unsatisfactory.  Not  a  few  writers  believe 
that  it  is  the  forerunner  of  atrophic  rhinitis,  laying  the  majority  of 
cases  that  occur  at  the  door  of  uncured  liypertrophy. 

Bishop  says  that:  "After  middle  age  the  hypertrophies  generally 
are  absorbed  aiul  disappear,  when  this  form  often  becomes  merged 
into  atrojihic  catarrh."' 

I  seriously  doul)t  the  correctness  of  this  statement,  ]mrticularly 
with  regard  to  age,  as  the  large  majority  of  cases  of  atrophic  disease 
that  have  come  uiuler  my  observation  have  been  many  years  under 
the  period  of  middle  age.  It  is  also  generally  accepted  by  rhiuologists 
that  atrophic  rhinitis  has  reached  its  term  by  middle  life,  and  from 
that  time  gradually  disappears,  or,  at  least,  the  dislres-iiig  symptoms 
])ass  away. 

Treatment.— 'J' he  kind  of  treatment  reijuired  deijeiids  largely 
upon  the  extent  and  severity  of  the  disease.  If  the  liypertrophy  be  of 
a  mild  character,  producing  only  slight  stenosis,  alkaline  spray.s,  fol- 
lowed by  mild  astringents,  may  be  all  that  shall  be  reipiired.  The 
solutions  referred  to  in  the  treatment  of  purulent  rhinitis  wnuld  also 
lie  suitaiile.  to  wbiih  list  miLrbt  be  adiled: — 

1.     U  Zinci  siiliiliiit 2 

Glvccriiii   21 

Aquaiii     iul  301 

H. 

1.     B  Zinci  sulphat gr.  iij. 

Glyccrini  wxxx. 

Aquaiii     aJ  5j- 

* 


k: 


it 


o2  DISKASKS    OF    TlMv    NASAL    I'ASSAfiKS. 

1.     It  (.'anii)hoi-incnthol    1 

Alboleiie SO 

Tlic  mmilxT  of  ciisi'.s.  liowcvcr,  in  wliicli  r^iiiiplc  spniy-tioatment 
will  elTect  a  cure  is  very  limitod.  I'liticnts  usually  delay  seeking 
advice  \intil  pernianont  hypertrophy  has  taken  jilace,  to  remove  which 
operative  treatment  of  one  kind  or  another  is  required. 

For  this,  two  methods  of  operating  are  largely  in  vogue.  One 
is  l)y  the  application  of  chi'omic  acid;  tlu;  other  by  lh(!  use  of  the  gal- 
vanocauteiT.  'I"he  first  has  the  advantage  of  cheapness  and  simplicity 
of  management.  The  nasal  fossa  is  first  sprayed  with  a  2-per-cent.  so- 
lution of  cocaine.  This,  in  three  or  four  minutes,  will  produce  general 
shrinkage  of  the  mucous  nuMnhrane,  with  the  result  of  widening  the 
fossa.  Then  a  stronger  solution — .«ay.  S  to  10  per  cent. — may  be 
apjilied  to  the  turbinated,  on  a  cotton-holder,  to  remove  the  remain- 
ing sensibility.  To  apply  the  chromic  acid,  first  dip  the  end  of  a 
slender  bent  probe  into  mucilage;  then  pick  up  with  it  two  or  three 
crystals  of  chromic  acid,  and  hold  them  in  tiie  tlame  of  a  gas-jet, 
until  they  fuse  into  a  head  on  the  end  of  the  probe.  This  cools  in  a 
moment  and  can  be  apjilicd  to  the  hypertrophic  tissue.  A  small 
eschar  is  formed,  which  in  a  few  days  separates,  reducing  the  swelling. 
The  ojieration  can  be  rcjicated  several  times,  at  intervals,  until  the 
re(iuired  amount  of  reduction  has  l)ecn  accomplished.  The  chief 
thing  to  guard  against  in  using  the  chi'omic  acid  is  the  possibility 
of  touching  other  jiarts  while  carrying  it  to  and  from  the  diseased 
tissue.     Care  in  application  should  ])revent  any  accident  of  this  kind. 

The  second  method,  by  the  use  of  the  galvanocautery.  is  mucli 
more  generally  followed,  particularly  by  specialists.  The  chief  diffi- 
culty is  the  cost  of  expensive  apparatus;  l)ut  the  advantage  lies  in 
the  thoroughness  of  treatment  and  the  ni<'ety  and  precision  with 
which  the  operative  woi'k  can  l)e  (bme.  For  this  ])urpose  the  various 
forms  of  sforage-batteries  are  usually  employed.  These  can  be 
charged  with  electricity,  at  any  works  where  electric  light  is  manu- 
faciurcd.  as  fre(|uently  as  the  expenditure  of  the  current  may  require. 
T?i  towns  and  cities  lit  iiy  electricity,  transformers  can  be  constnu'ted 
in  c(mnectiou  with  the  ])lant.  and.  when  furnished  with  the  reipiisite 
re>^istance-coil.  are  always  ready  for  use.  In  urlian  sections,  where 
storage-l)atteries  cannot   be    regularly  charged,   the   plunge-batteries 


1.     R  ('aniiilior-incnthol    gr.  xv. 

Alholono    3j. 


IlYl'KHTHOI'llK'    HIIINITIS. 


53 


answer  a  very  ji;oo<l  purpose.  1  have  latterly  u^■e<l  a  lautery-trans- 
former  connected  with  the  alternating  current  I'rum  the  city  electric 
works.  It  docs  excellent  service,  heing  constantly  controllable  as  well 
as  easily  regulated. 

In  Fig.  47  is  shown  a  Ballanl,  l-volt,  two-celled  storage-battery 
that  I  used  for  years.  On  the  top  the  metal  l)ars  comprise  the  adjust- 
able volt-selector,  by  which  the  current  may  be  made  of  2-  or  4-volt 
power.  For  cautery-work  only  2  volts  are  recpiired;  for  electric  light 
4  volts  are  needed.  I  ii  front  of  the  battery  is  seen  t  he  rheostat  by  which 
the  cautery  can  be  regulated  froni  a  dull-red  to  a  white  heat.     I'^ig.  4T 


Fig.  47.--I5iillai(l  yalvanocautt  ly-liatti  ly,   with  cord, 
handle,  and  knife. 

also  gives  a  galvanoeautery-liandle  wiih  knife  and  also  shows  electric 
cord.  In  this  case  the  two  cords,  for  convenience  sake,  after  separate 
coating,  are  wrapped  together  in  a  single  wel).  As  will  be  noticed, 
the  two  ends  for  attachment  to  the  cautery-handle  are  separately 
covered  with  rubber  tubing.  This  is  to  positively  prevent  their  touch- 
ing each  other  when  attached  to  the  battery  in  circuit,  as,  should 
this  occur,  the  instrument  might  be  destroyed  i)y  short  circuit. 

To  operate  with  the  cautery-knife  successfully  requires  both  care 
and  skill  on  the  part  of  the  operator.  The  ]iarts  should  first  be 
thoroughly  cocainized   and   the   nostril   opened   and   protected  by   a 


£    If 


If 

tic 


m 


i 


i 


54 


DLSKASKS    Of    TllK    NASAI,    I'ASSACilCS. 


largo-sized  speculum  (Fig.  13).     Shurly's,  with  its  ivory  septal  pro- 


ad  i 


ibk 


th 


V 


)tliei 


tcctor,  is 

like  the  ovoid  the  best,  a»  tiiey  slip  into  the  nostril  and  j)rotect  the 
vhole  circimirereiice.  The  speculum  in  jxisitioii,  tlie  cautery-knife 
'i!^  l)assed  into  the  naris  and  directly  back  to  the  posterior  end  of 
the  enlargement  to  be  operated  upon.  'J'lic  current  i.>  then  turned 
on  at  a  bright-red  heat  and  an  incision  made  into  it  from  behind 
forward.  When  the  turbinal  hypertroi)liy  is  very  large,  jiresenting  a 
round  j)rojecling  surface,  J  have  usually  applied  the  ilat  side  of  the 
instrument,  cutting  in  jiretty  deeply.  1  know  this  is  contrary  to  the 
ordinary  teaching,  but  I  have  found,  after  the  slough  has  separated, 
tliat  there  has  still  been  abundance  of  my.xomatous  tissue  and  epi- 
thelial coating  to  heal  perfectly,  without  leaving  a  scar.  In  doing 
this  care  must  be  taken  not  to  have  too  wide  a  blade,  and  to  confine 
the  application  to  the  one  width  of  the  llattened  surface  of  the  elec- 
trode. 

On  the  other  hand,  when  the  hypertrophy  is  less  prominent  and 
less  enlarged,  a  slight  knife-edge  cauterization  will  produce  the  best 
result.  It  is  well  in  either  case  not  to  operate  too  extensively  at  one 
sitting;  and  we  should  always  be  as  conservative  in  our  operations  as 
the  nature  of  tlie  case  will  allow.  After  operation  the  passage  should 
lie  s[)rayed  out  with  albolcne  or  glycolin,  fur  its  cleansing  and  pro- 
tective effect;  and  a  tampon  dipped  in  the  same  hydrocarl)on  should 
be  inserted  between  the  cauterized  surface  and  the  sei)tum.  This  will 
prevent  any  possibility  of  adhesion,  and  it  should  be  left  /'/(  .s(7«  for 
thirty-six  to  forty-eight  hours. 

The  best  iiu'thod  (if  (ipeiatiiig  upon  large  hypertrophy  of  the 
posterior  end  of  the  inferior  turbinated  is  sometimes  a  vexed  cpieslion. 
Many  authorities  advise  removing  the  hypertrophy  with  the  cold 
snare.  This  done  by  the  slow  turning  of  a  Jarvis  snare  is  a  tedious 
and  painful  process,  even  after  free  cocainization,  ])articularly  as  it 
may  take  from  half  an  hour  to  an  hour  to  separate  the  mass.  Any 
severe  traction  or  ])ulling  upon  the  jiarts  is  likely  to  do  serious  harm, 
as,  if  resorted  to,  it  may  loosen  the  attachment  ox  the  turbinated  bone 
itself. 

Other  authorities  advise  the  galvanocautery-snare  as  being  speedy 
and  cflfectual.  The  olrjection  may  lie  nrgcd  that  the  large  surface 
exposed  during  the  operation  to  the  action  of  the  heated  wire  contains 
a  considerable  element  of  danger,  particularly  when  we  remember  the 
close  proximity  of  the  growth  to  the  Eustachian  tube.    When  resorted 


llYl'KHTUOriUC   imiMTis. 


to,  tlie  lingor  should  invariably  be  passed  behind  tiio  i)alat(',  to  adjust 
the  wire  and  insure  the  safety  of  the  tube  itself. 

In  my  own  experience,  I  have  had  better  results  in  the  treat- 
ment of  ordinary  posterior  turbinal  hypertropliies  by  operation  witli 
the  tliit  electrode  than  by  any  other  niclhod.  After  ai)plying  a  10- 
or  lo-jicr-ccnt.  solution  of  cocaine  freely,  I  have  jiasscd  the  electrode 
back  through  the  nostril  to  the  growth,  guiding  the  application  of 
the  cautery  liy  the  post-rhiiial  mirror.  'J'his  sometimes  r('(|uir('d  a 
little  training  of  the  patient;  but  I  would  not  venture  to  o])erate 
without  I  could  see  the  point  of  the  instrument  clearly  rellecled  in 
the  glass.  This  being  recngtiized,  a  lirm  hand,  guided  by  a  knowledge 
of  tlic  anatomy  of  the  part*,  -should  ])erl'orm  the  operatimi  without 
risk.  The  growtli  is  large  and  vascular,  and,  pressing  the  electrode 
flatly  upon  the  centre  of  its  inner  side,  you  can  burn  dnwii  ih'eply 
into  it  without  producing  pain.  The  one  cauterization  is  all  that 
should  be  done  at  one  sitting.  In  this  case  tamponage  is  not  neces- 
sary. It  may  be  followed  by  swelling,  but  scarcely  enough  to  touch 
the  septum;  and  a  daily  sjiray  of  weak  solution  of  cocaine,  followed 
by  albolene,  will  help  to  kct'p  it  open.  In  three  or  four  (lay<  the 
mass  will  slough  away,  aiul  the  o])eration  can  be  repeated  carefully  at 
intervals  until  the  turbinated  returns  to  its  normal  ;■!/(•:  l)ut  one  or 
two  rc'jietitions  are  all  that  arc  ever  required,  and  in  >onie  cases  a 
second  burning  is  not  needed. 

I  have  never  known  niiddle-ear  disease  to  arise  from  tbif  method 
of  treatment,  but  1  have  seen  several  instances  in  which  tinnitus 
aurium  and  slight  deafness  have  been  removed  l)y  it. 

Of  course,  tliis  nH.'thod  of  reducing  the  hy[)ertropliy  shoidd  not 
be  attempted  by  the  inexperienced  operator.  ^Vilat  may  he  one  man's 
food  may  be  another  man's  liane,  and  any  individual,  by  constant 
])ractice,  may  liecome  so  skillful  in  the  use  of  a  sinu'le  instrument  as 
to  prefer  it  to  all  others  in  the  performance  of  certain  operations. 

Ifelot,  of  l?ouen,  recommends  the  use  of  electrolysis  by  the  bi- 
polar method  for  the  treatment  of  posterior  hypertrophy.  The  parts 
are  first  cocainized,  and  then  the  electrodes  are  passed  through  the 
anterior  naris  and  inserted  side  by  side  into  the  enlargement.  'l"he 
si'dinrs  last  five  minutes  or  more,  and  are  repeated  at  intervals  of 
several  days  until  the  hy]iertrophic  tissue  shrinks  away. 

During  the  last  two  years  a  new  method  of  treating  severe  cases 
of  this  disease  has  been  discussed  and  practiced  by  many  l-'nglish  and 
I'hiropean  rhinologists.     On  this  side  of  the  oc(>an  the  ])lan,  although 


m 


50 


DlSKA^^Kt*    ()!•    Till-;    NASAI.    I'AISSACKS. 


iiccoptod  ill  a  iiiodilicd  di-gn'o,  luis  not  been  j)ructice(l  in  its  entirety 
to  any  great  exleiil.  This  is  o])eration  by  tiirbineetoniy,  or  removal 
of  the  tiirl)inate(l  body.  The  term  "turbinotomy"'  has  also  been  ap- 
jilied  indiseriniinatt'ly  to  tliis  operation;  but  as  this  term,  from  its 
derivation,  really  mean.-  simple  incision  ol'  tlie  Uultiiiated,  its  ase  is 
searcely  appi'opi'iate,  and  i'onse(|iiently  should  not  be  applie(l  to  the 
operation  at  all. 

Tiirbineeltiiiiy  may  lie  partial  "or  eomplele,  and  it  is  the  latter 
that  has  been  so  strongly  ai'  oeated  in  certain  cases  by  Carnialt  Jones, 
Dundas  (iranl,  Jiaber,  and  bers.  For  this  a  sjieeial  instrument  has 
been  made:  L'arnialt  Jones's  spokeshave,  modilieations  of  wliieb  are 
re])resented  in  Fig.  II.  After  cocainization  the  entire  turbinated  can 
be  removed  by  it.  its  n>e  i>  only  adNocated  in  <'.\trciiK.  cases,  where 
milder  opei'ative  measures  have  failed  to  give  the  nninired  relief. 
This  .severe  and  I'lidical  operation  is  opposi^l  by  many  surgeon.-,  par- 


l''iji.  48. — Kiii;;lifs  nasal  si'issiois. 


tieiilarly  in  .\nierie-a.  on  aceount  of  the  imimrtant  posilinii  which  the 
inferior  turbinattd  occupies  in  normal  respiialion. 

!Modilletl  turbinectomy,  on  the  oilier  band,  is  accepted  by  all 
rhinologists.  and,  in  ajipi'ojiriate  eases,  is  constantly  being  done.  F^re- 
(piently  the  anterior  cud  of  the  middle  turbinated,  bulging  and  press- 
ing n]ion  tlu'  .-cptum,  can  be  better  excised  than  binned  away.  And 
can  be  removed  ell'edually  by  means  ol'  serrated  scissors  (Fig.  48). 
The  anteriiu"  end  of  the  inferior  turbinated,  likewise  curled  upon  itself 
and  filling  the  whole  of  tlie  inferior  meatus,  can  often  be  best  removed 
by  cutting  instruments;  and  partial  turl)inectoniy  in  either  case  would 
be  unattended  by  the  intlaniniatory  swelling  which  might  be  expected 
from  extensive  cautery  operation.  The  same  applies,  tliough  in  a 
modified  degree,  to  the  posterior  end  of  tlie  infeiior  turbinated.  Fig. 
id  shows  forceps  specially  designed  for  nasal  work  tlie  spring  closing 
the  instrument,  and  pressure  opening  it. 


MYl'KinilOI'llK      KIllNII  IS. 


•  )« 


Tlio.se  vjuidu.s  uji(.'iiilii)ii»  can  bo  |K.'rl'i)riiii(l  iiiulor  cociiiiic  iiiia'.— 
tliL'^^ia  by  jiicans  of  various  iiistruiiu'iils,  such  as  curvrd  .scissors, 
knives,  ])uneli-l'oi<e|)s,  (Iriiiiwald's  typical  uiciliod,  (ir  I'vni  .-aws 
properly  guarded.  1  ba\c  liciiufiilly  used  the  last-named  instrument 
in  excising  the  niiich-ciirved  anterior  end  ol  the  interior  turl)iiialetl. 
In  (Iriinwald's  operation  a  not<'li  is  cut  in  the  neck  n\'  the  middle  tur- 
binated, or  near  the  central  part  id'  the  lower  turliinated,  and  the 
part  thus  marked  oil'  is  reinosed  by  hoi  or  cidd  snare. 

llowevei'  well  complete  or  e.vteiisive  turbineciomy  may  sinl  the 
moist  and  saline  atinosidiere  of  CJreat  JJritain.  in  the  drier  climate  i>\' 
the  I'nited  Stales  and  Canada  it  can  rarely,  ii'  ever,  be  rei|uired.  It 
is  quite  jiossible  thai  entire  removal  wouhl  leave  >iich  an  atrophic 
condition  thai   ihe  cure  would  be  worse  than  the  disease. 

A  method  (d'  trt'atmcnl  has  been  advanced  by  j,eiuii)\  Umu  ne 
diirini;'  ;he  last  year  which  is  wni'thy  uf  11111113  c\tcn>i\e  trial.     It   is 


]'ijr-    ^!'-       ^llUllv"s    Ilil-ill     fci|rc|i-.. 

by  clectroeantery-i)uneture  <d"  the  liypertroi)hic  tissues.  After  co- 
cainization  a  sharp  needle  is  jiassed  deejily  into  the  enlargement, 
[taralhd  with  the  wall  of  the  fossa.  Il  is  left  in  sihi  at  a  red  heat 
for  a  few  nunnent-^  and  then  removed.  Uy  this  means,  while  the 
mucous  membrane  is  .^avi'd.  the  hypertroithie  tissue  shrinks.  The 
method  1  would  consider  jiarticularly  ap[ilical)le  to  postciiui-  hyper- 
trophies, special  care  being  taken  not  to  puncture  the  Eustachian  tulie. 
Still  another  method  of  ireatnu'iit  has  been  pi'oposed  by  Uryson 
Dclavan,  somewhat  similar  to  the  lasi  inenfioued.  the  dill'ercnce  being 
that,  instead  of  cautery-puncture,  we  have  submucous  knife-incision. 
After  cocainization  a  small  Idaded  ophthalmic  knife  is  passed  into 
the  hypertrophic  tissue  without  perforating  the  opposite  side.  A 
slight  sweeping  movi'iuent  is  made  as  the  knife  is  brought  out  of  the 
same  opening.  Kelief  is  usually  pr(im]it  and  fnlldwcd  by  no  un- 
pleasant results. 


iff 

■II.)! 


ClIAlTKll  VIII. 


ATHOI'llIC  lailNlTlS. 


This  discas-c  lias  lictii  kmiwii  I'or  ^'onorations  liy  tlio  nanio  ol' 
calarrli,  liciiig  considered  a.s  si^iiilicant  of  nasal  discharge  accom- 
panied hy  fold  odor.  Catarrh,  however,  is  not  a  disease.  Init  a  symp- 
tom, and  as  a  symptom  it  dilfers  widely,  both  in  character  and  degree, 
according  to  the  pathological  conditions  t<i  which  it  owes  its  origin. 

Among  the  many  detlnitions  of  atrophic  rhinitis  given  hy  lead- 
ing anthoi's,  I  know  of  none  more  terse  and  comprehensive  than  that 
of  Wyatt  Wingrave,  who  says:  "It  may  be  delined  as  a  progressive 
and  persistent  form  of  dry  rhinitis,  characterized  hy  a  shriidvage  of 
the  mucous  mend)rane,  which  tends  to  invade;  contiguous  chand)ers, 
and  is  accompanied  by  the  formation  of  crusts,  with  more  or  less 
ffctor  of  a  special  character." 

Pathology. — In  the  atrophic  slate  the  normal  cdia  lining  the 
mucous  mcmbi'ane  (d'  the  lower  half  ol'  the  nasal  foss;e  are  gradually 
destroyed.  In  severe  cases  this  loss  of  the  ciliated  epithelium  becomes 
complete  and  permanent,  their  place  l)eing  taken  by  r  layer  of  ilat, 
squamous,  epithelial  cells  in  a  state  of  constant  desiiuiunation.  ]>elow 
this  the  cuboidal  ejiitheliuni,  the  adenoid  or  hyaloid  layer,  the  acinus 
glands,  the  blood-vessels,  and  eavenious  sinuses,  all  gradually  shrink 
away,  losing  their  power  of  physiological  engorgement  and  collapse, 
so  essential  to  the  proper  performance  of  the  respiratory  functions. 
This  atrophy  of  all  the  special  tissues  of  the  mucous  meml)ranc  is  ac- 
companied by  formation  of  abnormal  connective  tissue,  though  in  a 
minor  degree  than  when  the  result  of  hypertrophic  disease. 

Notwithstanding  the  shrinkage  of  the  turbinated  tissues,  Win- 
grave,  on  microscopical  examination,  fouiul  imbedded  in  the  inter- 
lobular tissues  of  the  glands,  in  the  lymphoid  tissues,  and  sometimes 
in  the  stratified  epithelium,  small,  round,  refractive  cells  \vhicl'  he 
called  hyaloid  bodies.  They  varied  in  size  from  one-eightieth  to 
one-thirtieth  of  a  millimetre.  Those  bodies  increase  in  numbers  as 
the  disease  advances.  Finally  they  break  up  into  minute  refractive 
bodies,  resemhling  spores.  The  question  of  the  nature  of  these  bodies 
(58) 


ATROPHIC    imiNITIS. 


8» 


is  still  undecided.    Some  biologists  believe  Ibem  to  be  the  bacteria  of 
atrophic  rhinitis. 

Klebs-Loefller  l)ueilli  iiiid  also  staphylococci  have  been  found  in 
large  numbers  in  certain  cases  of  atrophic  rhinitis  without  develop- 
ing either  diphtheria  or  general  suppuration. 

Microscopically,  multinucleated  lymjihocytes  arc  found  in  the 
atrophic  discharges  as  well  as  the  bacillus  fu'tidus  and  bacillus  of 
Friedliinder.  Aecfirding  to  Tjcnmix  iJrowne,  tlio  crusts  consist  of 
mucin,  cell-globidin,  and  serum-albumin,  with  traces  of  suli)hur  and 
l»hosphorus. 

l-'raenkel  and  Loewenburg  have  discovered  a  diplococcus  which 
they  claim  In  have  an  induciicc  in  (he  etiology  of  the  disease. 

Xolanil  Mackenzie  maintains  that  atrophic  rhinitis  is  a  sclerosis 
— a  chronic  intlammation  in  which  there  is  an  atrophy  of  specialized 
tissue,  accompanied  by  mild  liypertropby  of  cfninective  tissue;  that 
this  eonditidii  is  present  in  hypertrophic  as  well  as  atrophic  disease; 
that  the  two  (lill'er  not  in  kind  l)uf  in  degree,  the  one  being  hyper- 
trophic sclerosis,  llie  other  atro])hic  sclerosis. 

v..  T-.  Shurly  believes  tlie  disease  to  be  a  pure  neurosis  of  central 
origin. 

Incidental  jialhological  changes  occur  in  a  majority  of  cases. 
Out  of  (»(»  recorded,  the  ]iliaryngeal  and  fnucial  tonsils  had  entirely 
disappeared  in  50;  while  in  the  remaining  4  they  were  small,  thiis 
indicating  a  direct  relationship  between  the  surrounding  lymphoid 
structures  ami  the  atroiiiiic  disease. 

Perforation  of  the  cartilaginous  septum  is  of  frequent  occurrence. 
It  is,  however,  geiu'rally  Ix'lieved  to  he.  not  so  much  the  direct  result 
of  the  disease  itself,  as  of  digital  picking.  Tn  my  own  experience,  I 
do  not  remember  a  case  of  jierforated  septum  co-existent  with  atrophic 
rhinitis  in  which  I  could  not  trace  the  origin  of  perforation  to  the 
period  of  childhood.  When  it  comes  under  the  notice  of  the  physician, 
the  margin  of  the  perforation  will  usually  be  found  coated  with 
tenacious  mucus,  overlying  a  layer  ol'  ju-oliferated  epithelium.  The 
whole  history  of  these  cases  of  ])erforation  would  appear  to  support 
Bosworth's  theory,  that  purulent  rhinitis  in  children  was  the  fore- 
runner of  the  subsecjuent  atrophic  disease. 

Etiology. — Perhaps  there  are  few  subjects  in  medical  science 
upon  which  there  exist  so  many  dilFerenccs  of  opinion  as  upon  the 
origin  of  atrophic  rhinitis.  Fraenkel  was  the  originator  of  the  idea 
that  it  was  a  sequel  of  hypertrophic  rhinitis,  and  a  large  number  of 


1  II 


Si 


■4 


m 


till 


DISKASKS    (M'    Tin:    NASAI.    I'ASSACi  KS. 


(ilwcrvLTs  art'  still  of  tlu'  same  oj)iiiic)ii.  Scilur  says  tliat,  wiiili!  il  may 
l)e  till'  result  (if  liyjxMti'ophy,  it  may  also  be  atrophy  from  the  start. 
J)rakt'  claiiiis  dn'oiiii-  |iiiiiik'iit  iiillaiuiiiatioii  ol'  the  accessory  sinuses 
as  the  cause,  (lottsteiii  holds  that  (lei'eetive  development  of  the  tur- 
liinated  hollies  may  be  responsible  for  the  disease.  ]\layo  Collier  has 
thrown  out  the  suggestion  that  it  may  yc:  he  diseovered  that  the 
initial  (li>ease  was  degeneration  df  the  lU'i'vo-ganglion  and  nerve-ilhres 
supplying  the  pai'ls.  !•].  L.  Shiirly  soiiu'what  I'avors  Collier's  idea,  for 
he  has  long  been  of  the  opinion  that  it  was  essentially  a  tro])hic 
neurosis  of  central  origin.  r>osworth,  on  the  other  hand,  in  his  recent 
i>sue  of  liSiKI,  expresses  as  em]ihatically  as  ev  ■]■  the  belief  that  the 
disease  is  the  result  of  a  previous  attack  of  infa.  .ile  purulent  rhinitis. 
(ielli  als,)  favors  Ibis  theory. 

Personally  J  have  seen  a  great  many  case>  in  young  ])eople  which 
could  I'e  1 !  iced  back  direcily  to  jmrulent  rhinilis  of  childhooil.  In 
examining  these  cases  there  was  no  history  whatever  of  previous 
hyjiertrop  e  disease:  but  there  was  the  history  of  chronic  ])urulent 
discharge,  dating  hack  as  far  as  ineinoi'v  could  reach.  1  helicve,  loo. 
thai  it  i^  ]H)s.-ible  for  atrophy  to  \)v  a  seiiuel  to  hypei'trojtby,  for  I 
have  seen  cases  in  whicii  the  relationship  ap])eared  to  exist;  b\it  1  do 
not  bcli(>vo  that  i'   is.  hy  any  means,  the  rule. 

\\'c  rircly  meet  with  bypc'trophy  of  the  turhinaieils  during 
childhood:  as  a  I'ule,  it  is  a  disease  of  early  adult  life;  and  il  is 
'Veil  to  icniemher  that  llie  majoiily  of  eases  o\'  atrophic  distvise  like- 
wise otcni'  in  young  men  and  women.  Jt  would  seem  impossihlc  for 
a  slow  liypei'ti'oj)hi('  process  to  have  time  for  development,  and  that 
to  oe  followed  by  suilicieiit  shrinkage  to  jiroduce  afro])hy  at  the  lime 
of  life  when  ue  ai'i'  usually  called  in  to  treat  these  cases. 

(^hiili'  fi'iMpienlly  alro|ibic  rhinitis  is  unilati'ral.  intirely  conllned 
to  the  one  nasal  cavity,  and  that  one  the  widest,  with  a  curved  .-ep- 
tum,  the  convex  surface  within  the  narrow  nostril.  There  may  lia\e 
been  no  prcvicuis  purulent  disease;  and  lln.'  c(Miclusion  seems  reasmi- 
ahle  that  the  great  width  of  the  fossa  had  allowed  free  breathing. 
whil(>  pcrmiiliiig  the  retention  of  di>cliai'ge.  'The  retained  secre- 
tions would,  in  time,  become  iiuiulcnt.  Criist-fin'malion  would  fol- 
low, Mhieli  eventually,  hy  it>  repeated  presence  and  ])ressure,  would 
produce  greater  slirinkage  (d'  ti.<sue. 

Symptomatology. — The  -ymiitonis  are  eharae  eristic  and  too  well 
known  to  reipnre  a  careful  delineation.  They  consist  of  dryiu ss  of 
nose  and  throat,  the  latier  in  consequence  of  the  former,  accompanied 


ATllUI'lIlf    ItlllMlh 


61 


1 


liy  lOi'iiiatioii  I'!'  crusts  within  tln'  nasal  cavities.  'I'iic-i  are  nl'tcii 
tliiliciilt  to  blow  uul;  and.  as  the  disjcase  advances,  it  heconies  im- 
possible, by  Nature's  elToii  alone,  to  thonniiihly  remove  them. 

On  rliino.-copie  examination  the  fossa'  will  i)rove  t<>  I'C  ciihirized 
to  a  greater  or  less  extent,  acc'ordin>i'  to  the  severity  nl'  tlic  disease. 
the  enlargement  being  due  to  the  shi'ink.ige  nf  the  middle  and  in- 
fei'ior  turbiiiate(l  bodies,  (ireeiiisii-vellow  eiiisi-.  \\iih  a  eliai'aeter-  • 
istic.  oU'ensive  ud(ir,  will  partially  hll  the  |ia.-sage>;  and  mi  the  I'e- 
niii\al  of  the.-e  llu'  ;niiei)us  mendiraiie.  although  nnlu'oken  by  uleei'a- 
lioii.  will  jiresL'iil  an  unwontedly  sep.nken  and  pallid  appearance. 

.in  this  disease  the  nnrmal  >ei'(ius  discharge  iiec(inie>  limited,  and 
iiually  almost  ceases,  having  the  air  diy  and  I'nul  by  the  time  it 
reaches  the  thi'oat.  With  diuiiiiutioii  nf  seiniis  thud  theri'  i>  iii<Tea,-e(l 
exiolialion  of  epithelial  and  pu.—  cell>.  These  tngelher  iiieru-t  ai.  1 
(leg  up  tiie  pas.-ages.  In  Imig-slanding  ease-  anosmia  i^  <>['  Ireqiieiit 
oei-urreiice.  while  in  many  the  seii.-e  of  ta,-te  i.-  like\\i>e  impaireil. 

I>i'yness  id'  throat,  or  phaiyngiti.-  >ieca.  i-  alway.-  a  ic-ult  in  ad- 
sarii'ul  eases;  ami.  as  C(dlateral  events,  the  I'aucial  and  pharyngeal 
Icuisils  n.-ually  ln'c(une  atrnphie;  ihe  eontigiMUs  siiiu>e>  mil  inlVe- 
([Uently  beeonu'  involved,  and  the  Mu-tacdiian  tidies  ni;iy  also  be 
all'eotcd. 

A\'liile  the  oll'ensi\e  l\elor  pi-culiar  to  .Urophic  rliinili.-  is  usually 
lielieved  to  ari-e  from  putitd'action  of  the  retained  sei-reii(ms.  '\"in- 
gra\e  has  advanei'd  a  new  and  somewhat  jilausible  theory:  lie  ,-ays 
that,  as  the  mueous  membrane  i>  a  tran^foi'med  epidermal  -iruitiire, 
having  with  its  glands  a  common  origin  with  the  skin;  so  iii  this  dis- 
ease we  have  a  structural  rever;-ion,  in  the  .-iratilication  of  ihe  siii-face 
epitlioliiim.  to  the  pi'imiti\c  type:  and  in  the  glands  there  i-  estab- 
lished a  perverted  function,  the  miicou-  membrane  being  convertt'd 
into  cutaneous  structure,  .villi  a  cori'e-poiiding  change  in  s.^crelion. 
F<illowing  out  this  line  of  argunieiit,  he  speak<  of  the  various  odors 
produced  by  dillV'reiit  ]Mn'tions  of  the  skin,  smdi  as  the  feet,  the 
axilla',  the  pi'epuce.  etc..  and  (dainis  thai  the  odor  of  atrophic  rhinitis 
has  a  direct  kinship  with  these. 

Diagnosis.-  -I'Accpt  in  its  earliest  stage,  a  cand'id  and  thiu'oimh 
examination  should,  with  little  dilliculty,  ex(dude  cvt'iy  other  disease. 
'{'here  is  one  remarkable  fad.  that,  after  the  crusts  have  been  caicfully 
and  thoroughly  removed,  no  matter  how  attenuated  the  turbinated 
tissues  may  have  become,  ulceration  will  always  be  an  ab<enl  (jiian- 
lity.     Of  course,  where  sejital  perfoi'ation  exists,  there  may  be  ubera- 


iH 


6« 


DISKASKS    Ol-    Tin;    NA^Al,    I'AS^AtiKS. 


tion  around  its  maigin;  but  the  perioration  dates  hack  to  an  earlier 
date  than  the  atrophic  disease.  Syphilis,  on  the  other  hand,  is  often 
the  cause  of  oxtonsive  ulceration  of  the  hone  as  well  as  soft  tissues; 
hut  the  odor  of  atrophic  rhinitis,  while  disgusting  enough,  is  still 
distinct  from  that  of  syjihilitic  iK'crosi«. 

Prognosis. — ^Vithont  ireiitnicnt,  prognosis  is  liad.  With  treat- 
ment, relief  can  be  ol)tainod.  and  the  conditinn  very  much  improved, 
and  in  a  few  casos  cured.  Hut  this  ;  an  only  lie  accoiupli>li('d  by  care- 
ful and  thorough  treatment,  carried  out  for  years  in  many  cases. 

Fracnkel,  of  Berlin,  says,,  referring  to  atiopliic  rhinitis:  "A  cured 
case  of  oza'iia  is  unkiu)wn  to  me."  liosworlh,  in  bis  la.-t  edition,  says: 
"In  the  early  stages  of  the  disease,  before  the  ftttid  symptoms  set  in. 
T  have  seen  cases  recover.  In  the  advanced  stages  characterized  by 
fo'tor,  and  in  wliieh  the  turbinated  boues  have  ahnost  entirely  disap- 
jieared,  I  have  not  seen  a  case  cured.  :''  ''y  cur(,'  is  meant  a  conilition 
secured  in  which  there  remains  no  neci'ssity  t'oi'  any  measure  of  local 
treatment."  Sajous  says:  "Atrophic  rhinitis  is,  perhaps,  the  most  un- 
satisfactory of  the  na.-al  alfectious  to  treat  .-ut-cessfuUy."' 

All,  however,  agree  that  much  can  lie  done  In  amcliorair  the 
symptoms  and   make  life  comfortalile 

Treatment. — The  ini.ial  step  is  always  to  tlnuouglily  cleanse  the 
uasal  and  naso-pharyngca.'  cavities,  rcnuiving  completi'ly  all  incrusta- 
tions wlicrever  located.  This  is  best  accomplished  i»y  the  use  of 
aqueous  alkaline  s))rays,  such  as  Dobell's  .-dluiinu.  to  iln^  anterini- 
nares;  and  the  i;se  of  the  post-nasal  spray-syringe,  by  which  water 
at  the  temjjcrature  of  100°  V.  can  be  thrown  forcibly  through  the 
nostrils  from  behind.  For  the  latter  purpose  a  Davidson  syringe 
with  a  curved  spray-tube  attached  is  an  admirable  instrument.  Tlie 
tube  l)eing  jias.-ed  up  behind  the  palate  and  the  patient's  head  tii)ped 
well  forward  over  a  receiving-bowl,  a  constant  stream  id'  a  piiit  (U* 
more  may  lie  readily  thrown  througli.  This  not  ludy  loosens  the 
concretions  witliiu  the  nasal  passages,  but  also  those  beliind  the 
])alate;  and.  even  if  it  does  not  bring  them  all  away,  it  materially 
softens  them  and  facilitates  their  removal.  Other  iii-t  ■timcnts  ( l''igs. 
.')()  and  od*;)  act  upon  the  same  principle,  although  le-s  ell'cctively. 

The  method  of  using  the  nasal  douche,  and  instructing  tlu'  pa- 
tient to  pass  1  or  3  (piarts  of  hot,  medicaleil  thiid  daily  through  the 
nose,  up  one  nostril  and  down  tlu'  other,  wliich  is  often  recommended, 
only  accomplishes  jiart  cd'  tlie  object  in  view.  It  Hoods  the  nasal 
passages.  l)ut  not  the  na-o-pharyn\;    ami  in  this  disease  it  is  as  im- 


I 


ATKOPIllC    lUIIMTIS. 


03 


portant  to  cloan.se  the  uno  as  the  other.  If  the  iio.-e  during  the  douch- 
ing is  elevated  enougli  to  allow  the  tluid  to  pass  beyond  the  soft 
palate,  there  is  serious  risk  of  flooding  the  Miistachian  tul)es,  an 
accident  involving  much  danger  to  the  inner  car.  Tlic  use  of  the 
post-nasal  syringe,  carefully  adjusted  well  up  beliind  the  soft  palate, 
with  the  head   tipped   forward,   is  dcvuid   of   this  danger,   while,  as 


Hi 


Fig.  50. — Post-nasiil  syringe. 

already  stated,  it  cleanses  the  combined  nasal  and  post-nasal  region, 
and  conse(iucn(ly  is  preferable  to  the  former  method.  It  also  simpli- 
fies the  treatment,  as  ])aticnts  cnn  be  taught  to  i)ractice  tlie  one  as 
readily  as  the  other. 

The  anterior  na.'-al  spray  from  a  good  atomizer  is  a  good  adjunct 
to  the  post-nasal  treatment.     Still,  when  tlie  disease  is  severe,  the  two 


.^ffi" 


^ 


(*W«LL  SU"  -w»t  .0 


Fip.  iV-W. — Postnasal  syringe. 

together  will  not  elTectually  cleanse  the  jarts  from  crusts.  Tn  com- 
plete the  removal,  the  nasal  cotton-carrier  by  the  anterior  nar.'S,  and 
the  curved  cotton-carrier  by  tlie  nnso-pharynx.  will  1)oth  l»t'  required 
In  first  treatments  especially  tiiis  should  i)e  done  in  a  painstaking 
and  thorough  manner,  and  always  by  the  aid  of  anterior  and  posterior 
rhinoscopy  with  a  good  refiected  light 


-■  ■,<),. J 


i    i 


i<   .  ,1 


y 


64 


i)i>i;Asi;s  OK   riii:  nasai,  passack.s. 


This  stcj)  liiniiiL;-  liccn  ;u(()iii]»lislR'(l,  it  is;  generally  coiioodod 
tliiit  till'  next  one  i<  tn  siiniuliite  tlie  atrophic  inenil)rane  to  a  bettor 
])erfonnance  of  its  natnral  riiiiciinn  df  secretion.  To  this  end  (iott- 
stein  reeonmiends  jihiggiiiii  the  mi^li'ils  Inr  twcnty-rour  lionrs  witli 
cotton  tani|HMis.  When  ihcv  me  iciniivcd  a  How  of  mucus  Inllows  the 
siiinuhiliim.  A\'heii  the  llnw  -iih-ide-.  tlic  cavities  ar,'  cleansed  a.^rain 
and  l'f(  sli  tainjiniiv  inxitcd  'I  lie  whole  procedure  is  I'epeaii'd  as  i'rc- 
(jUenilv  and  for  as  Ion,::'  a  |ieriod  a.>  recpiired. 

A\'oakes  uses  (iott^tein".-  |)lni:s  foi'  tin'  pni'pose  of  applyinu'  pow- 
ders of  a  .-tininlatinu'  cliaracler  to  liie  uiseaseil  niendirane.  Sajons 
advises  the  n.-i'  of  tlie  iialvanocjinlery  passed  rapidly  over  the  snrfaces, 
and  T>enno.\  lirowiie  favors  the  .-aine  plan  with  snhseipient  insnillation 
of  iodol  or  iodohu'n).  Shindy  and  ISryson  l)(devan  reeoniniend  the 
galvanic  enrri'iit.  tlie  jiositive  eh'ctrode  being  ])laced  on  the  napo  of 
the  iieek.  and  the  negative,  wrapped  in  alisorbent  eotlon.  to  the  in- 
t(  rior  of  the  no-e.  Hidevaii  uses  fr(nn  l  to  7  niillianiperes  with  a 
duration  of  from  -even  to  lifteeii  minutes  at  eaidi  sitting,  until  serous 
discharge  occur>. 

Other  method-  of  tri'atment  are  the  n>e  of  stimulating  s[irays 
after  the  clean.-iiig.  -iicli  as  -(dntions  of  thynio].  creasote,  argent 
niti'ate.  etc.,  of  varying  strengths;    but  these  are  of  donbtfiil  value. 

Another  method  of  treatment  originated  by  IJraun,  of  Trieste. 
several  yeai's  ago.  and  which  from  its  enthusiast ii'  acceptance  by  his 
cotuitrynieii.  might  lie  calleil  the  Italian  method,  is  that  of  vibratory 
massage  of  the  miicou-  membrane.  Outside  of  Italy  either  in  Kurope 
or  Amei'ica  it  lias  not  lieen  received  with  any  marked  favor;  but  I 
am  glad  to  -ee  that  r>isho|i.  ir,  his  recent  work,  speaks  faviu'ably  of 
]iiassage.  i'er.-onally.  from  my  own  expi'rienee.  I  indorse  his  views, 
though  each  of  ns  has  niodilied  bis  practice  to  suit  his  own  individual 
eases.  As  reeoinnieuded  by  Ib'anu.  an  olivo-poi]ited  probe  is  passed 
within  the  nostril.  It  is  held  b(>tween  thumb  and  linger  like  a  pen, 
aud  the  vibrations  are  in-odiiced  by  the  clonic  rhythmical  niovemeiits 
of  the  hand  and  forearm  of  the  opcM'ator  as  he  ])rosses  the  olive  jioint 
against  the  uiucous  niembraue.  i>y  practiic  these  contractions  are 
said  to  mimber  aliout  fmir  hundred  per  minute. 

The  mucous  membrane  <d'  each  nasal  fossa  covers  between  thirty 
and  fiu'ty  stpiari^  ceulimelres.  and  the  siiaee  operated  on  will  bt'  about 
one  sipiare  centimetre  at  a  time.  T'.raun  says  he  makes  the  time  of 
each  vibratory  apjilication  about  five  minutes  to  each  nostril.  lie  also 
precedes  the  treatment  liy  the  application  of  cocaine. 


ATKOPHIC    RHINITIS. 


(55 


To  relieve  the  fatigue  of  tlic  oiieralor,  as  well  as  to  make  the 
vibrations  more  rapid  and  nniform,  electromotor  instruments  have 
been  made,  from  wliich  their  originators  claim  to  have  produced  even 
better  results  than  hy  maimal  vihralidii. 

])ishop's  modification  is  by  using  an  ordinary  cottnii-holder,  or 
probe,    lie  wraps  the  end  with  a  lonsf  wad  of  cojoii.  and.  passing  it 


into  the  nostrih  hv  hand-vihration  cnnilmn'-  the  dm 


Ihic 


iinrpo; 


=0  of 


cleansing  and  massage. 

My  own  incthnd.  and  frdin  wjiii-h  1  \\;\\v.  seen  excclh'nt  results, 
is  sninewhat  dilTerciit.  i  have  practii-etl  it  now  fur  several  year-. 
After  tiioroughly  cleansing  the  fossa.  I  wrap  a  jdedget  of  absorljent 
cotton  firmly  and  closely  round  th(>  end  of  ilie  liolder,  in  the  form 
of  an  olive-siiapcd  lip.  'i'liis  is  dipped  in  aJlHilene  and  \\<vi\  hy  hand- 
vibration  according  to  i'>raun"s  inetliod.  A  tier  each  viltratory  move- 
ment the  cotton  is  .~lippeil  olf:  and  with  a  fi'W  twii'ls  lietween  tluimli 
and  finger  anotiu'r  one  applied.  One  advantage  cd'  tiiis  nu'tliod  is 
that  the  firm  cotton  tip  can  he  made  of  any  simpe  aud  sizi>  to  suit 
the  various  crevices  within  the  nasal  cavity.  I  may  also  add  that, 
for  nuissage  so  applied,  1  never  tind  ii   necessary  to  us(>  cocaine. 

Sometimes  after  removing  the  ineiii.-taf ion-  a-  tiioroughly  as 
possilde.  even  with  the  after-i reatmeid  of  massage,  a  thick  layer  id' 
tenaciniis  e)iitheliiiin.  ]ii'ojecting  from  llie  lower  border  of  the  middle 
or  inferior  tui'liinatc(ls,  will  still  <]:(}■  nil  clVorts  at  cleansing.  To 
remove  this  tlii'  application  of  a  Iti-per-t  cut.  soluti(Ui  of  nitrate  of 
silver  ti»  the  spot  will  sonu'timt'S  he  suiluient:  hut  1  have  usually  oli- 
taincd  the  best  results  hy  singeing  the  proliferation  with  the  galvano- 
cautery.  This  should  never  he  carried  to  the  extent  of  destruction 
of  the  whole  epithelial  coaling.  As  a  result,  the  pale,  bloodless,  striivjy 
membrane  would  give  place  to  a  pinkish  one  of  more  healthy  color. 

One  pecidiarity  of  formation  I  have  observed  in  several  instances. 
In  each  case  it  was  confined  to  the  side  alfectcd  by  the  more  marked 
atrojdiy.  This  was  the  attachnuMit.  by  a  cicatricial  liand.  of  ])art  of 
the  inferior  border  of  tlu^  middle  turbinated,  either  to  the  upper 
part  of  the  lower  one  or  to  the  external  wall  of  the  middle  meatus. 
These  special  instances  seemed  to  owe  their  origin  to  a  ]n'e\iiiu- 
hypertrophic  condition.  Tn  treating  thon.  affer  ajiplying  cocaiu(\  I 
liavc  separated  the  attachment  by  the  galvanocautery  with  advantage 
to  the  ])rogress  of  the  case.  One  thing  more  T  may  add:  that  for 
years  now,  after  cleansing  and  massage,  instead  of  com]deting  each 
treatment  by  the  use  of  some  stimulating  spray,  I  have  obtained  the 


1  f  t 


is  t 


I,. 


(JG 


DISEASES    01'    THE    NASAL    I'ASSAGES. 


most  satisfactory  results  to  my  patients  by  simply  fini.shing  with  a 
spray  of  one  of  tlie  hydrocarbons.  As  said  before,  these  bland,  in- 
odorous, aseptic  j)reparations  are  soothing  and  grateful  to  tlie  patient, 
and  act  as  protectives  to  the  whole  lining  of  the  mucosa. 

For  home-treatment  the  patients  are  directed  to  U:^i^  the  post- 
nasal .syringe  first,  at  least  once  a  day;  and  follow  this  up  with  sprays 
of  albdlene  or  glycolin  at  intervals  of  several  hour:;,  until  they  return 
to  the  ofTico  again  for  more  thorough  treatment. 

The  solutions  nsed  in  the  post-nasal  syringe  may  consist  of  1  per 
cent,  of  any  of  the  folhiwing,  in  water  at  a  temperature  of  100 
degrees: — 

]\luriate  of  anunonia. 
Chlorate  of  potassa. 
(  hloride  of  sodium. 
Boric  acid. 
IJesorcin. 
Oi'  '.'  per  cent,  of 
JUborate  of  soda  or 
Bicarl)onate  of  soda. 
Or  a  -"i-jier-cciit.  solution  of  jxToxidf  of  hydrogen. 
Those  answer  very  well  for  a  time,  until  the  patients  have  be- 
come familiar  with  the  jio.st-nasal  method  of  treatment.     1  have  sub- 
secpiently  obtained   ])etter  results  l)y  having  them  nse  simple  clear 
water  at  as  high  a  temperature  as  they  could  comftji'tably  bear. 


ClIAl'TKK  iX. 


(EDEMATOUS  KIIINITIS. 


1 

i 

,  1 

■'    u! 

1 

Tiiic  earliest  mention  I  can  iiml  of  iliis  ili.sea.«e  is  jn  the  report 
of  the  American  .Laryngologieal  Association  for  181J;).  Jn  his  jjaper 
J.  C.  Mulhall  dcscrihes  it  as  a  serous  inlilti'atioii  of  the  middle  or  in- 
ferior turhiiiateds.  It  is  remittent  in  eliaraeler  am!  may  ije  unilateral 
or  iiilateral.  It  may  aho  be  migratory  and  either  acute  or  chronic. 
When  punctured,  serum  slowly  exndes.  lie  says  cocaine  has  little  or 
no  influence  over  it.  It  may  be  associated  with  broncliial  asthma, 
but  only  in  a  minority  of  cases.  It  is  considered  to  bo  a  neurotic 
aireciioii,  yet  distinct  from  tlie  neurotic  diseases  which  are  caused  by 
extrinsic  excitants. 

In  treatment  ]\lulhall  says  that  sprays  are  contra-indicated,  and 
that  the  best  results  are  obtained  by  scarification.  If  nasal  deformi- 
ties are  present  they  should  be  removed.  In  treatment  the  alimentary 
canal  and  the  general  system  should  be  carefully  attended  to. 

This  is  a  rare  disease,  and  I  have  only  seen  one  well-marked  case. 
The  ])atient  is  a  young  man,  aged  2(i  years,  of  sedentary  occupation. 
A  number  of  vears  aao  I  removed  a  larue  spur  for  him,  and  also 
cleared  the  naso-pharynx  of  adenoids,  to  remove  the  stenosis  from 
which  he  was  suifering.  For  a  couple  of  years  lie  was  free  from  any 
difliciilty  in  nasal  respiration.  Tlu'ii  the  stenosis  commenced  to  recur 
again,  sometimes  very  suddoily.  Previous  to  the  attack  tin  septum 
and  turbinateds  would  appear  perfectly  normal,  and  there  would  be 
no  dilVicuUy  whatever  in  breatliing  through  either  side.  Then  from 
cold  taken  from  exposure,  or  su(Men  dropping  of  oIlicc-tcmpiTalure, 
one  nostril,  within  an  hour  oi'  so,  would  bn-nine  completely  blocked. 
I'xamination  wonld  ri'veal  one  fossa  (juite  (bar,  ili>'  oilier  absolutely 
closed,  a  pale,  serous-looking  onlenia  distcmling  the  mucosa  of  both 
the  s(  ptum  and  inferior  turbinated  of  the  alfected  side,  and  the  parts 
bathed  in  muco-serum.  On  examining  the  throat,  the  posterior  rhino- 
scofte  would  reveal  the  corresjionding  choana  tilled  by  the  gray, 
swollen,  inferior  tur])inated  body. 


m 


HCH 


68  i)isi:.\si:s  or   riiic  nasal  tassacucs. 

Unlike  Miilliall,  I  found  the  niiplicalidii  nf  a  l-per-cent.  solution 
of  cofjiinc,  passed  slowly  ilir<niL,di  the  nostril  upon  a  cotton-rarrior 
and  applied  freely  to  the  whole  length  ol'  the  luri)iiiatpd.  would,  on 
eacli  ooeasion.  give  speedy  relief.  The  charging  of  a  good-sized 
pledget  would  he  all  that  would  he  reipiired,  and  iu  live  luinutes 
resj)iration  through  the  passage  would  he  restored.  I  found,  also, 
after  rejx'aleil  trials,  that  the  relief  ohiained  woidd  ho  very  much 
prolonged  and  in  some  cases  would  continue  for  days,  if  the  cocaine 
trcatiuent  was  su])j)leiuented,  as  soon  as  the  passage  hccanic  clear,  by 
a  spray  of  thyiuo-meulhol  of  the  following  strength: — - 

1.     n  Tliyiiiol    |13 

J^rcnthol     1| 

Albolciu!    30| 

M. 

The  preparation  appeared  to  prolong  the  astringent  elTect  of  the 
cocaine  and  to  stimulate  the  tissues  to  moi'e  elTectual  control  of  the 
vasomotor  vessels. 

Quite  frequently  the  (cdema,  after  occurring  for  two  or  three  suc- 
cessive days  on  one  side,  woidd  suddenly  cease  and  appear  again  in 
the  adjoining  cavity  in  just  as  severe  a  form,  disappearing  for  the  day, 
after  treatment,  to  occur  again  perhaps  twenty-four  hours  later. 

In  this  case  there  was  no  hypertrophy  whatever,  either  of  septum 
or  turhiuateds,  and,  when  the  attack  ])assed  otf,  the  parts  seemed  to 
be  in  a  ])erfectly  normal  condition.  Sonu^times  months  would  pass 
without  an^'  trouble.  In  every  otlu'r  way  the  young  nuin  was  in  a 
strong,  healthy  condition. 

During  the  fall  and  winter,  however,  ho  has  for  years  had  a  num- 
ber of  seizures;  and  the  ])resent  year  the  symptoms,  partieularly 
on  the  left  side,  with  ])articidarly  severe,  threatening  to  remain 
throughout  the  sunuucr  mouths  as  well.  CousiMpuMilly  T  decided  to 
make  a  deep  galvauocauti  ry  incision  along  the  full  length  of  the 
lower  turhiiuited  on  that  side.  Vor  a  day  or  two  there  were  no  signs 
of  haunorrhage.  Then  it  eanu;  on  profusely,  ami  plugging  with  kite- 
tail  tampons  had  to  he  re.<^orted  to.  They  were  worn  nearly  a  week 
and  then  extracted  piecemeal  for  several  days  longer,  the  fossa  being 
washed  daily  by  sprays  of  2-per-cent.  cocaine  and  V„  per  cent,  of 


rj   'riiynidl    pr.  ij. 

Mcntliol     pr.  XV. 

Albolene    5j- 

M. 


(KDHMATOIS    HIIINITIS, 


C!) 


h}mol  ,„  .lyn-lin.  The  tissues  seem  to  he  a^ain  un,l.r  control,  and 
lor  weeks  now  tiio  ..dcMnn  has  coa.scd  to  occur.  Whether  the  advent 
of  he  changeable  autun.nal  season  will  hrin^^  it  hack  again  ronu.in.s 
to  be  seen.  ' 


I. 

i,; 

ill! 

I'll 


-■  r- 


I'llAl'TKU  X. 


FUJKINOUS  RHINITIS. 


qf' 


'I'll IS  is  nn  acuU'  iiithiiniiiatiim  ul'  the  iiiucoiis  iiioiiiliiaiie  of  the 
nasal  passajffs.  attciKU'il  by  a  di'j)Oi-it  of  fibrinous  exudation  upon  its 
surfaces.  Il  jiiisi'nts  tlic  patiioloi.Mfal  fraturi'.s  of  false  iiRinbraiie 
inipoi-ed  upon  tlic  epitlu'lium  witlioul  invol\iny  llie  deepei-  tissues. 

As  most  of  tin;  eases  of  membranous  rliinitis  that  have  occurred 
and  been  examined  have  been  simply  an  extension  of  diplitheria  de- 
posit upward  into  the  nasal  cavities,  many  observers  still  Ijelieve  that 
it  is  always  of  diphtheritic  origin  and  the  result  of  the  presence  of  llie 
Klebs-Loolller  bacillus. 

IJecent  experiences  aeconi]!anied  by  careful  clinical  and  [)atho- 
logical  examinations  have  proved,  however,  that  this  is  not  the  case. 
Fibrinous  exudate  within  the  nasal  passages  of  non-diphtheritic  origin 
does  sometimes  oecur,  and  it  is  of  this  I  nnw  speak. 

In  18!)3  tile  ''Transact ions  of  the  I'aliudngieal  Society  of  Lon- 
don" contained  ,"n  exhaustive  article  upon  the  subject.  In  it  Abbott. 
while  leaning  toward  the  idea  that  all  iase>  were  of  a  niildly- 
<liphtheritic  characler,  states  positively  that:  '"It  cannot  lie  too  often 
insisted  upon  that  the  true  nature  df  all  membranous  do})osits  upon 
the  mucous  membrane  of  the  aii-pas-ages  (referrijig  to  tlie  nose)  cai\ 
only  be  definitely  I'evealed  by  bnet(  I'iologieal  research":  a  tacit  ad- 
mission that  non-diphtheritic  mendorane  might  exist. 

In  \>^\i[  Ih'un  .Murdoch,  at  the  laryngological  section  of  the 
British  ^ledical  Association,  reported  a  case  of  recurrent  nunnbranous 
rhinitis  wliich  dccurred  in  a  female  aged  ,'5o  years.  During  a  little 
more  than  a  year  she  suffered  from  six  different  attacks  without  any 
indications  of  true  diphtheria.  A  number  of  bacteriological  exami- 
nations of  the  false  membrane  were  made;  but  all  failed  to  show  any 
Klebs-Loenier  bacilli,  although  a  number  of  micrococci  of  no  special 
'moment  were  ])vesent. 

The  symptoms  weie  at  lirst  those  of  slight  head-cold,  rapidly 
getting  worse  and  continuing  for  several  days,  with  complete  occlu- 
sion of  nostrils.  Abmit  the  fifth  day  white  membrane  would  appear 
in  the  anterior  iiares.  This  would  scale  off,  leaving  the  parts  some- 
(70) 


IIHUIMM  h    ItlllMTlS. 


71 


wlial  raw  and  tlic  iinsc  swollen,  'riu'ix'  was  no  rise  of  ti  in|>(,'raUnx'. 
but  sovort'  sneezing.     Tiic  wliole  attack  would  last  al)out  a  I'ortnighl. 

Jlot  bathing,  iodolVtrni,  menthol  in  iluid  vasclin,  cocaine,  I'lc, 
only  sliglitly  relievtd  the  syiii|itoMis.  .\t  diu'  time  i^'aUanocjiiitcrv- 
singeing  produced  partial  relict. 

In  the  same  year  Si-hillVr  read  hd'orc  tlie  Uclgiaii  Socii'ly  ol' 
Otology  and  i.iiryngology  a  papi'r  on  the  "Pathogenesis  (d'  N'on-in- 
fectiotis  Croup  (d'  the  Nasal  Mucous  Mend)ranc,"'  with  lin'  histoiy  id'  a 
case.  'J'he  mcndtranc  was  ciinlincd  to  llic  nasal  cavitic?-.  The  general 
symptoms  were  slight,  save  for  the  iiiisal  mendiranous  ohstrnetioii. 
!Microscoj)i(al  examination  pioved  the  ahseiu^e  of  the  Klei)s-L(i(dller 
liacilliis.     'I'Ik  le  was  no  si^n  id'  the  disease  lieiivi  infection-;. 

In  18!ts  Middlemas  Hunt,  in  a  paper  nn  "''I'lie  lielatioii  of  l'il)ri- 
nous  TJhinitis  in  r)iphtheria,"'  reported  four  cases  <d'  lii)rinous  rhiniti>. 
In  two  of  tliese  ther,'  were  no  indications  of  Klebs-Locdiler  liacilli.  in 
the  other  two,  although  none  was  discovei'cd  at  the  time,  diphtheria 
followed  in  the  one  ])aticnt  two  weeks  later,  and  in  the  i'amily  id'  the 
other  after  a  similar  interval.  In  cdiieludiiiL:'  his  artiide  ilnni  uses 
tliese  words:  "T  am  afraid  there  are  no  elinieal  characters  on  which  we 
can  rely  in  distinguishing  the  two  diseases,  and  our  one  method  i.-  to 
turn  for  help  to  tiie  skilled  bacteriologist." 

Richard  Lake,  of  still  later  date,  gives  ihe  history  (d'  a  case  of 
clironic  pseudomcndn'anous  rhinitis,  occurring  on  the  right  ^ide.  in  a 
man  aged  5-1.  He  was  a  hay-fever  subject.  Treatment  had  only  a 
temporary  otf'ect:  and  when  he  returned  for  examination,  ten  months 
later,  the  membranous  disease  had  increased  in  severity.  Microscnjiical 
examination  revealed  the  staphylococcus  pyogenes  aureus  in  abun- 
dance, but  no  Klebs-Loefller  bacilli. 

In  March,  1S!)S,  I  reported  an  idiopathic  case  of  membranous 
rliinitis  to  the  Toronto  ^ledical  Society.  It  occurred  in  a  young  lady, 
aged  IT  years,  an  abstract  account  of  which  appeared  in  the  Journal 
of  Lari/Hffdhifjj/.  May,  1899.  This  was  unilateral.  alTecting  and  closing, 
for  the  time,  the  left  nasal  fossa.  Tlic  membrane  was  whitish-}  ellow 
and  inodorous  throughout.  It  extended  to  the  jiosterior  naris,  l)ut 
not  into  the  ii.iso-pbarynx.  The  treatment  consisted  of  applications 
of  cocaii. e,  sol'itions  of  nitrate  of  silver,  and  albolene.  There  was 
no  fever.  Microscopical  examination  discovered  no  Klebs-Ijocdller 
bacilli,  but  a  large  and  jntre  culture  of  staphylococci  was  made  from 
the  membrane.  The  cure  was  completed  in  about  three  weeks  of 
regular  treatment. 


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IMAGE  EVALUATION 
TEST  TARGET  (MT-S) 


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U£  1^    |2.2 

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—    6" 


Photographic 

Sciences 
Corporation 


33  WEST  MAIN  STREET 

WEBSTER,  N.Y.  UiSO 

(716)  873-4503 


37 


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UlfSKASKls    Ol'    Tlili    NASAL    I'ASSAliES. 


With  it'l't'ic'iu'f  to  tliu  statement  that  a  simihir  false  meinhrane  is 
always  produced  by  the  appliiation  of  the  galvunocautery  to  the  nui- 
coiis  surface,  it  must  be  remembered  that  tlie  ])rotective  covering  is 
only  formed  upon  the  sjjots  cauterized,  whereas,  in  fibrinous  rhinitis, 
the  whole  mucous  lining  may  be  aU'ectcd.  Sometimes,  however,  the 
cllVct  of  cautt'rization  is  not  so  limited,  and  the  burning  of  a  single 
spot  within  the  iia'^al  cavity  may  induce  the  formation  of  false  mcin- 
biiine  throughout  the  fossa.  Although  this  fact  is  well  known,  the 
literature  upon  the  subject  is  so  meagre  that  the  rcjxirt  of  a  case  nuiy 
not  be  without  interest. 

In  September,  1895,  a  young  lady,  aged  Ji5,  a  farmer's  daughter, 
came  to  me  for  tieatmcnt  for  hay  fever.  On  examination  there  was 
nothing  unusual  in  the  appearance  except  that  the  inferior  tur- 
binateds  were  very  inuch  enlarged.  Otherwise  they  had  the  ordinary 
pale  hue  usually  present  when  hay  feA'cr  exists.  Under  cocaine,  1 
burned  both  the  iiilerinr  liodies  througli  the  ceiitrt'  froiu  behind  for- 
ward. Twenty  iiours  later,  on  her  return  for  irealment.  both  nares 
were  slenosed  and  the  whole  lining  mucosa  of  each  passage,  so  far  as 
it  could  be  seen,  was  covered  with  falst'  membrane.  All  that  I 
could  do  for  her  relief  was  the  application  of  cocaine  followed  by 
vaselin.  Tiu'  mcmlu'ane  Ixcame  thicker,  but  retained  its  clear,  white 
color  willioul  odor.  In  two  days  it  commenced  to  loosen,  and  I  re- 
moved it  gently  in  large  Hakes  with  the  forceps.  The  recovery  was 
rapid  and  the  relief  of  the  hay  fever  complete. 

Two  years  later,  in  September,  18!)T,  she  returned  again  for 
treatment  for  hay  fever.  She  said  she  had  noiu'  the  previous  year. 
On  examiiuitiiiu.  the  inferior  turbinateds  were  all  right,  but  the  middle 
ones  were  eniaiged  aiul  pressing  on  each  side  against  the  septum. 
These  1  also  cauterized,  though  much  less  extensively  than  the  in- 
ferior ones  (in  llie  furmer  occasion.  1  also  took  the  precaution  to  in- 
sert a  small  pledget  of  cuttcin  on  each  sidi'  between  the  septum  and 
lb»>  middle  bodv. 

When  she  returned  to  the  ollice  on  the  following  dav  the  old  con- 
dition  was  repeated.  The  whole  mucous  membrane  on  each  side  was 
coated  with  white,  fibrinous  nu-mbiane.  and  the  treatment  and  history 
was  but  a  repetition  of  what  occurred  two  years  before.  On  both 
occasions  it  was  undoubtedly  traumatic  pscudonu'mbranous  rhinitis, 
but  it  was  unaccompanied  by  fever.  1  regret  tha.  lu.  bacteriological 
e.\aniinatit)n  was  made  on  either  occasion.  Other  writers  have  re- 
])orted  similar  ca.scs  resulting  from  cautery-work. 


HCTff- 


1     I 


FIBIUNOUS   RIllMTIiS. 


73 


In  dosuv^r  this  chapttT  I  inny,  perhaps,  vfiiturf  to  draw  the  follow- 
ing conciiihions: — 

1.  That  non-(li|ihthcritif  i)scMi(loiiu'iiihranous  rhinitis  doi's  soino- 
tiiiK's  occur,  and,  thoii^i^^h  a  very  rare  discas...  it  is  probably  as  frequent 
as  primarif  nasal  diphtheria. 

2.  That  on  clinical  grounds  alojio  it  is  possible,  in  a  niajoritv  of 
cases,  to  distinguish  it  from  genuine  diphtheritic  disease. 

3.  'J'hat,  owing  to  a  possible  mi.<take  in  diagnosis,  isolation  in  all 
cases  should  be  imperative,  until  a  reliable  bactcrioh.gical  examination 
can  be  made. 

Since  writing  the  above  an  aide  i;rticle  has  app.'ared  upon 
"Fibrinous  Khinitis"  from  the  pen  of  (JiM,  Wishart,  in  the  Septmi- 
l<er  issue  of  the  Lun/n,jos(ope.  In  it  h-  gives  the  history  uf  sev«'n 
cases,  two  of  which  were  benign,  wlnle  live  exhibited  th.;  Klel)s- 
J-oetller  bacillus.  Jle  also  sums  up  all  the  ca>es  of  which  he  can  find 
a  record,  totalling  98:    (JU  with  Klebs-Loelller  bacilli  and  l>!»  without. 

In  conclusion,  while  he  recognizes  that  many  observers  consider 
fdn-inous  rhinitis  a  distinct  disease,  he  believes  that  the  accumulated 
evidence  proves  the  following  points: — 

1.  Fibrinous  rhinitis  and  dii.hlheria  are  not  distinct  diseases. 

y.  All  cases  of  fibrinous  rhinitis  need  the  same  preciiutions  as 
to  isolation  that  diphtheria  requires. 


*    f. 


11 


II 


iti 


\1' 


M. 


i' 


DKroliMITIKS  OF  TIIK  NAS.M.  SKITI.M 

In  adult  lil'f  ^('|ilal  ilcfdrmit  ics  arc  tlic  iiih>i  rrr(|iii'iit  caii-r,  ii'U 
only  "if  calanliiil  aUV'ctions  ol'  tlic;  nasal  passajrcs,  but  also  of  (k'fcftivc 
and  iunt|iial  nasal  lircatliinLT.  What  seems  .eti'an;j;e  is  that  these 
deviations  from  the  normal  in  symmetry  should  ho  conlincd  so  largely 
to  the  civilized  raees  of  mon.  This  is  borne  out  by  examinations  of 
the  skulls  of  civilized  and  aboriginal  races.  In  the  museum  of  the 
lioval  College  of  Surgeons,  I^ondon,  out  of  '-.Mo".'  skulls,  it  is  reported, 
on  reliable  authority,  that  over  TO  per  cent,  have  irregularities  of  the 
se|»tuni.  ( ►n  the  other  hand.  Sir  Morel  Mackenzie  and  Zuckerkandl, 
after  carefully  examining  a  large  luunber  of  the  skulls  of  the 
al)origines  of  America,  Africa,  and  Australia,  found  only  •?<•  per 
cent,  of  the  nasal  cavities  presenting  osseous  abnormalities.  Allen 
examined  the  skulls  of  !•!}  negroes,  and  found  dcthntions  and  irregu- 
larities iji  only  I'l   per  cent. 

liecenily,  in  Toronto,  at  the  Arclutological  Museum  of  Ontario, 
whicli  eontains  the  most  '  \haustivc  collection  in  Canada,  I  examined 
220  Indian  >kulls.  by  far  the  largest  number  of  tiu'm  being  llurons 
and  Irf)(|uois.  One  hundred  and  eight  were  all  in  wiiich  the  septa 
were  sutliciently  well  marked  to  base  a  judgment  upon.  The  result, 
however,  was  diil'erent  to  that  of  the  observers  already  mentioned. 
Of  the  lOS,  51  had  deviated  septa  and  51  had  straight  ones,  or  50  ])cr 
cent,  of  each.  Of  the  number  I  were  Flatheads  from  British  Colum- 
bia; 2  had  deviated  septa,  2  had  straight.  Two  others  were  Mound- 
builders  from  .Arkansas,  of  ]>re-Columbian  history.  1  liad  deviated 
septum  and   1  straight. 

I  miglit  add,  as  a  curiosity,  that,  among  a  number  of  skulls  of 
Egyptian  mummies,  only  one  was  suHiciently  unwrajjped  to  admit  of 
examination.  In  this  the  septum  was  straight;  but  the  left  inferior 
turbinated  was  wedged  against  the  j)osterior  end  of  the  vomer.  This 
archaeological  specimen,  three  tliousand  years  old,  was  an  exlremi' 
exception  to  the  general  rule;  for  almost  invariably  when  the  septum 
was  straight  and  centrally  situated  there  was  nothing  abnormal  in 
the  condition  of  the  turbinated  bones. 
(M) 


iii;i  i»i{Mri'ii:s  or   iiii:  nasai,  skitim. 


«t> 


'( 


To  iiini  ill  tlic  cdndilions  in  iicliuil  life,  ('nlli<'r  ri'|)orts  that,  out 
(if  ](•*)()  iuliilt  |iiitifiits  cMiMiiiicd  iii(lisci'iiiiiiiitlt'ly  at  tlic  Xortliwcsi- 
Loiidoii  lldsiiital,  only  lid,  or  alioiit  1(1  per  cent.,  had  iiorniai  nnso. 
a  lariro  propoilion  licitiLr  aircclcd  hy  pi^pial  doviatimis.  In  cliildron  np 
to  the  aizf  ol"  ('ii:li(  (ir  ten  years  tlic  scpla  as  well  as  t iirltiiiatods  wcit 
generally  normal  or  ahnost  so-  any  olistriiriioii  nt  that  early  aire  hein^ 
usually  eansei  y  lesions  other  than  bony.  Fijrs.  51  and  i)\(K  taken 
from  a  fro/en  seetiim  cd'  a  eliilil  a,;:e(l  .")  years,  is  a  striking  e.\eo|»tiiin 
to  this  rnle,  the  deviation  and  the  spur  to  the  left  heing  stron,i:ly 
marked. 

in  the  nni'iiial  nnse  tin-  -eptiim  is  .-imply  a  hony  and  eartikminoii.-. 
Willi,  dividing,'  it  e(|nally  into  two  symmetrieal  fos-sa*.  In  all  tin'  lower 
animals,  in  ynnnir  children,  and  in  the  lower  untutored  races  of  men. 
this  is  still,  in  larj'e  measure,  the  ease.  I'ul.  !is  you  a]tproaeli  aduli 
life  amotiH-  the  eivili/ed  races,  septal  deformities  appear  in  lari^e  iium- 
hers,  until,  as  repoi'ted  hy  so  many  oh-ervers.  the  percenla<r(!  of  these 
iiU'(|inilities  heeomes  e.vceedinjrly  ^n'cat. 

A  |iro])er  classification  of  these  deviation.*  would  he  diirniilt  to 
make.  (>nile  freipiently  the  septum  is  not  thiekciu'd.  Init  the  car- 
tila.irinous  portion  makes  a  full  convex  curve  into  one  or  other  na-al 
fossa.  In  other  cases  witli  the  curve  there  will  also  he  a  nuirked 
jjrojection  or  spur  (Ui  the  convex  side.  Ajrain.  spurs  or  conical 
projections  nniy  ajipcar  on  (/ite  or  hotli  si(h's  of  the  lower  end  of  the 
triaiiLMdar  cartila^a'  without  an;  curvature  of  the  ujiper  septal  wall. 
In  other  instances  a  longitudinal  ridi:e  will  appear  in  oiu^  fossa,  ox- 
teinling  backward  along  the  hase  of  the  cartilage  and  involving  also 
the  lower  jiart  of  the  vonuT.  while  the  upper  part  of  the  septum 
retains  its  integral  position.  Sonu'  septa  '  i.v"  a  douhle  curvature,  or 
ccHwavo-convex  form,  from  before  hackwanl;  iind  still  others  have  a 
sharp  longitudinal  notch  on  one  side,  like  the  i  ieho  of  an  open  book, 
with  a  })rojocting  pcriiendicular  ridge  on  tin,  ojiposite  si(h'  of  the  sep- 
tum. Synechia\  or  brid^'.s  connecting  the  bony  septum  with  the 
middle  or  lower  turjiijuited  of  the  sanw  siih",  are  jiot  infretpuuit. 
There  is  often,  too,  a  combination  of  several  irregularities  in  the  one 
nose;  while  last,  but  not  least,  almost  any  deformity  on  the  one  sidi 
of  the  septum  is  atl(>iuh'd  by  sonu'  deviation  from  the  normal  on  the 
other. 

Etiologfy. — This  is  a  niany-si(h'd  (piestion.  and  many  diverse 
views  are  held  upon  it.  Some  authorities,  I»os\vorth  among  the  num- 
ber, bcdieve  that  the  large  majority  of  cases  owe  their  origin  to  trau- 


f 


h' 


ll 


l)l 


IJISKASKS    OK    TIIK    NAS.vl.    TASSAiiKS. 


Iliati>lll. 


Ins   iiiillior 


"}•• 


'I'l 


II-    |M)iiit    (in    wliic'li 


\ny 


■  pec 


ial 


(■iii])li;isis  is  tliiit  tlic  (Icforinily  i?;  [iriiiiarily  tlic  result  ol'  tniimiatism, 
and.  sccdndarily,  of  a  slnw  inllaniniatdry  proci's.s  which  results  thore- 
rnini.""  /uckcikandl  lias  jioiiitcd  out  tliat  in  many  instances  a  narri)w 
.-triji  of  cai'tila^^e  lies  between  the  iirrpendienlar  plate  of  the  ethmoid 
and  the  vomer,  due  to  defective  ossili/ation,  and  in  eases  of  -eptal 
injniv  this  mi,iihl  readily  ^i\e  ri,-e  'm  lid.ijes  fdiiml  in  this  I'eninu. 

Iloe  draws  attention  to  the  fact  that  in  early  'ife  the  vomer  is 
divided  into  two  lamina',  separated  from  each  other  hy  a  thin  layer 
of  eartilaL^i',  which  is  prolonjred  forward  to  form  the  cartila^'inous  por- 
tion of  the  septum.  Ossilieation  hejiins  in  the  second  week  of  infantile 
life   in  each    plate,   hut    i>   not    eiunplete   ui 


111 


luhert  V. 


About   tl 


I  bird  year  union  eomnieuees  beiween  the  plates  frum  behind  forward. 
in  this  ease,  too,  it  is  not  complete  until  adidt  life,  and  sometimes 
never.  lliMiee  many  (d'  the  deformities  may  arise  from  overirrowth 
(d"  the  anterior  or  free  portions  of  the  plates.  This  would  also  account 
for  the  rarity  with  which  we  meet  this  deformity  of  the  |)ostcrior  end. 

Trcndeletd»urj;  bidieves  that  many  cases  arise  from  llu'  upward 
pressure  of  a  hi^bly-arclu'd  jialate.  Other  writers  believe  that  the 
deformity  is  produced  hy  overj;rowth  of  the  septum  in  a  confined 
spai'C.  iJarvis  ailirins  that  many  cases  owe  their  origin  to  heredity. 
and  reports  four  cases  (tccurrini:  in  one  family  in  support  of  liis 
view.  It  is  easy  to  believe  heri'dity  to  he  an  important  factor  in 
producing  intrana.sal  deformity,  just  as  it  is  a  ])olent  element  in  pro- 
ilucing  ty|H's  of  feature  and  id'  form.  As  an  instance,  I  might  men- 
tion that  one  of  my  patients,  a  boy  of  lU  years,  has  developriig  a 
curvature  of  the  septum  to  the  left.  His  father  had  a  curvature  to 
the  ieft.  also,  large  enough  to  jiroduce  almost  complete  stenosis  on 
that  side.  On  further  ini|uiry,  1  was  informed  that  the  grandfather 
had  been  a  great  snulT-taker,  but  that  he  always  took  it  through  the 
one  uosfril.  The  conclusion  is  obvious:  the  grandfather  had  trans- 
mitted the  tendency  to  the  son  and  grandson. 

With  all  this  mxdtiplicity  of  views  as  to  causation,  it  is  possible 
that  ^Fayo  Collier's  researches,  founded  upon  Zeim's  experiments  on 
young  animals,  may  have  struck  the  kt-y-note.  He  claims  that  these 
deformities  are  largely  due  to  tit  the  elTects  of  atmospheric  ])ressure, 
badly  eiiualized  wilhin  the  nasal  cavities.  In  his  investigations 
Zeim  would  completely  block  one  nostril  of  a  young  animal  with 
some  soft  substance,  efTectually  stopj)ing  the  respiration  on  that  side. 
This  would  be  left  in  for  a  long  time.    The  result  in  everv  instance. 


1  -., 


2  . 

a 
t  — 

4- 

5 

9 


4 
J 
G 


hi,:;.  .■)!.  I'm/iii  -iilimi  ,,f  iMr  Inad  i>l  ii  iliiM  ,i^ci|  :i  \i-ir~,  I.  Sn-- 
lioii  ili:nii:,'li  liii.k  |iiiil  (>l  i-\r.  _'.  l'(.-icTii.i  •iliiiioiil  cclN.  li.  Siipciinr  lur- 
iMliiiIrd  Imiiic.  4.  Miildlc  liirliiiMl(  (I  Ipniif,  ."..  .\m1iiiiii  n\  lli;;liin(nv,  ti,  Sep- 
tiiiii   ciirxril    III    ilic    liii,      7,    Inriiiiii    I  iirliiiiiiiiil.      s,   Sii|H'iiiir    iiumIii-.     !I. 

.Miildlf     iiiciilii-..        Ml.     Iiiini ,,|||~.        .(■■rniii     l'iiini.i-i'>     Aimimnii  mI 

.Mnsciini.   I 'iii\ci-.ii  \    ni    ruiiiiiin.  i 


"  III 


Ml 


Fig.   .">!<(.      I'lip/i'ii    -I'ciidii    (if   «iiiiir   child,    liikfii    two   rent  iiiii'l  ri'>   an 
U-rior  t<»  Vifi.  T)!.      I.   Anifii  ir  ctliiiioiil   cclU.     2.    Miiidic   tiirhitiatcii   lionc 
;{.  Scptmn  curved  In  (he  h'ft.      \.   Inl'crior  tniliiiiiilcd   lioiic.     .">.  Aiilriiiii   nf 
lii^'hiriiirc     (>.    Hard    pahitc.      7.    Niiiilt    nt'   inoiiih.      i  l''i'iiiii    l*riiiii'<Kf°s    An- 
atomical   Mn^i'iiMi.    1  iiix  cr»it  \    of  'Idroiiici.) 


I.'l 


i.r 


DKKOIIMITIKS    OK   TIIK    NANAI.    SKI'TIM. 


81 


and  lu'  trit'd  it  in  a  jrrcat  many,  \\a>  the  ainsi  of  tln'  (li'Vi'lippnicnl 
(Ml  that  side,  with  delU'i'tinn  nl'  the  SL'iitinn,  the  |iiilati'.  the  intci'inaxil- 
larv  and  fmntal  hones,  all  toward  the  IdocktMl  cavity.  At  the  same 
time,  tile  nnolistructed  cavity  wonld  lie  lamer  than  natural  ami  more 
fully  develo|ied.  'Die  reason  i^  the  rarrl'aelinii  dt  tlie  air  in  the  closed 
nostril  during  inspiration,  caused  hy  the  ru-li  nl'  air  throu<^h  the  open 
one.  with  the  conse(|U('nt  atmospiicrie  j.re,--iirt  iipnn  all  .-idcs  of  I  lie 
closed  cavity. 

Collier  applies  the  same  jiriiiciple  in  unilateral  na.-al  ohsl  ruction 
oceiirrinj,'  in  men  as  Zeini  docs  in  hi>  cxpciiniiiits  on  aninuils.  Of 
<'oiirse,  hid'ore  the  cirects  of  rarei'actidn  cniild  dccur,  iliere  must  arise 
i'l-Din  sdiiie  cause  partial  stenosis  of  mic  nasal  fn.-sa.  'riien,  in  due 
time,  tliou<ili  it  ini^dit  take  years  to  develop,  ihe  ic.-ulis  indicated 
\V(udd  he  likely  to  follow.  In  children,  and  many  of  the  cases  have 
their  oriiLMii  in  early  life,  tlu'  oli-^triiction  iniLdil  arise  from  nej^lectcd 
colds,  particularly  when  the  child  was  allowed  to  lie  too  consecutively 
on   one  side. 

Symptomatology. — The  principal  syni|)toni  is  that  of  nunv  or  less 
unilateral  nasal  sti'uosis.  The  secondary  ell'eet  is  a  ehaii^icd  condi- 
tion of  the  mucous  memhrane,  which  usually  culminates  in  a  chronic 
nasal  catarrh.  It  is  often  the  eiitarrhal  condition,  with  its  attendant 
throat-dropj)inji-,  which  chietly  altracls  ihe  patient's  attention;  and 
ho  will  frequently  present  himself  for  treatment  without  any  per- 
sonal knowledge  of  the  existence  of  ihe  stenosis,  owing  to  its  very 
gradual   development. 

St'ptal  deformity  will  freipiintly  give  rise  to  epistaxis.  The  pro- 
jecting surfaces  are  exjiosed  to  the  dust  with  which  the  air  of  n'spira- 
tion  is  often  loaded;  and  the  contact  of  tlie^e  particles  tui  the  walls 
of  the  capillaries  ])roduee  minute  lacerations  and  conscijuent  ha'inor- 
rhage.  And  it  must  he  ri'inemhered  that  it  is  from  the  septum  that 
the  nose  nsnally  hleeds. 

'JMio  voice  also  heconies  affected,  ]iartieularly  when  the  ileformity 
is  very  marked;  hut  this  symptom  is  I'oiumon  to  nasal  olpstructioii 
from  any  cause. 

Dullness  of  hearing  is  not  an  infrequent  symptom,  arising  from 
the  extension  of  the  catarrhal  condition  to  the  Mustaehian  tuhe.  In 
these  cases  straightening  the  septum  may  he  expecteil  to  he  followed 
\)\  imj)roveinent  in  h*  iring. 

Diagnosis. — This  can  only  he  made  positive  by  direct  examina- 
tion, for  which  reflected  light,  head-mirror,  nasal  speculum,  and  post- 


1^.  ill' 


s; 


i 


m 


lil^ 


8V 


IIISKAHKB    OF    TIIK    NASA  I,    l'A!St>Atli:s. 


I'liMiiil  iiiirrnr  niiiy  nil  \>v  n'muifil.  A  [iraitiinl  kn<»\vlf(l<.'t!  of  tlic 
|iarl.«  shdiilil  then  remove  all  (luiilit.  Soinclimcs  a  mistake  may  be 
iiiadc  liv  llii'  aiilcrior  I'lul  dl   the  iiiidiilt'  tiirliinatcd  heiiii.'  on  a  line 


witli  llie  s('|i|iiin.     At  this  spni 


;rni 


i|i  III'  |iroje('tiri|r  ji;lamls  may  liiih 


the  point  of  scparalion.  Cre.-Wfll  liakci'  call.-  this  spnt  '•tuliiMVuliiiii 
scjiii.''  Carel'iil  e.xaniiMatinn.  li(o\c\cr.  will  ca.-ily  rrmovc  llie  doiilit. 
Nasal  po|\|iiir;  ami  lilnonia  i<\'  tlio  .-('pliiiii  ar*'  hotli  m>ivaiil(\  while 
llic  sepliini  is  not.  'Tlie  rnrnicr.  too,  is  lijilitif  in  cnlnr  .md  sdl'tcr. 
while  the  latter  i-  darker  and  .  .dijrct  to  lia'inoiiliai:e  nn  the  .-li;:hte>t 

ftHlcli. 


Prognosis.     1, 


It    to  itself,   ni 


•plal  de\  ialinn  or  dri'orniity  wil 


inipiiAf,  and  the  symptoms  produced  hy  it  arc  likely  (o  remain  un- 
relieved. 

Jn  eases  wli'.ic  ilic  .-yiiipiuin>  arc  nci-ily  ealarrhal.  wilh  partial 
stenosis  on  the  allVcted  si<li  in  ii(i\;d  n\'  iho  nlistrneti(»n  should  he 
attended  hy  ^ood  re.-nlts.  In  ear  di>ea-e,  tuo.  ari.-in^-  from  this  cause, 
hcnelit  may  he  expected,  fnun  -imilar  tieatnient.  Tharyn^'eal  catarrh 
is  also  ^really  hcnedled  hy  rci-ioralion  (d'  normal  hreathin<;.  In  hay 
i'ev(  r  and  asthma,  these  disease-  lieinj,'  so  frctpienlly  I'cilcx  in  origin, 
improvement  will  often  fnlhiw  operatinii.  thoiiirh  the  proj.Miosis  should 
always  he  iruarded. 

Treatment. — The  removal  of  the  stenosis  produced  hy  the  de- 
formity is  the  mr-st  essential  IV-ature  of  treatment,  and  the  methnd.<i 
to  aecomplish  this  vary  materially,  accordini:  to  the  eharaeter  of  the 
lesion. 

Althoii<;h  fractures  and  displacements  of  the  ,-eptum  arc  of  fre- 
<pient  occurrence,  they  are  unfortunately  rarely  jiresented  for  treat- 
ment until  after  irrejrular  union  and  lualimj;  has  occurred,  and  the 
aftcr-elTeets  noticed.  When,  however,  the  fracture  is  fresh,  the  fra^r- 
ments  can  he  jiressed  hack  into  position,  and  retained  in  jdaee  1»y 
suitable  ruhher  or  cork  splints,  i  iit  to  the  retjuired  shape  and  placed 
within  the  nasal  ])assa^M's.  It  lias  heen  said  that  splints  are  not  re- 
((uirod  in  these  cases,  as  there  is  no  muscular  action  to  displace  the 
structures,  oiice  placed  in  position.  This  is  a  mistaken  conclusion. 
.After  fracture  there  is  always  swelling  or  o'dema,  and  this  itself  may 
M'parate  the  newly-adjusted  parts.  Blowing,  to  free  the  nose  frinn 
discharges,  may  also  interfere  with  the  ])ro|)er  union.  On  the  other 
hand,  a  carefully-adjusted  splint  inserted  on  the  side  of  depression 
will  support  the  fragments  without  ]>roducing  distress;  and  n  week 
or  ten  davs"  immohilitv  will  <ut!ice  to  elTect  the  d(>sired  union.    Thick 


i)i;i'uiiMriii:s  of  tiik  nas.m,  skittm. 


83 


riibliiT  splints  III'  iiK'diuiii  sdl'tni'sti,  carcl'iill}  adjii.-ttil  to  -iiil  tlu'  oi/c 
jiikI  (•(imlitiuii  of  the  pints,  arc  also  in  many  cases  of  ruivatun'  of  (lie 
fciO|iliiin  t'.\c;('i'(lin;.'ly  n.-cful.  If  \\<)ni  for  a  niiinlitr  of  \U'tks,  llic  coii- 
stanl  .*u|i|K)rl  tlifV  cllcc  t  will  restore  tli<'  |ias>a^'e  to  an  alnio.-t  n'T- 
innl  eontJition.  Tlieir  usefniness  is  Iiiirhly  ajipreeiated  iiy  Lalie  ami 
oilier  writers. 

Consolidiil.d  (Icformit'i  s  of  the  .-epiiini  are  treatid  in  \ar;on.s 
ways  liv  (liil'erent  aiiliu.i.-.  \\  here  projeetiii!'  .^j'tirs  ami  n(l>;es  pro- 
duce .ilistriiction,  idl  a;?ree  that  tlie  exostoses  and  liyperelmndria 
slioiild  lie  removed.  Many  believe,  witli  Mosworlli.  thai  tiioy  -honld 
he  excised  hy  means  of  saws.  'l"i  intention  is  to  lca\e  a  smooth, 
))lano  .snrfaee  over  which  mueoiis  ni  inhrano  will  ijniekly  form  with 
little  or  no  cicatrix. 

W  hen  tl'.e  distortion  propciil.s  its'M'  in  the  form  of  an  hyper- 
frophied  rid;.'e  or  spur  npon  tlie  eartilnir.iii.iis  portion  of  the  septum, 
this  can  freqiionlly  lie  removed  hy  means  of  a  sharp,  iiarrow-hladed 
knif''.  leavin.ir.  as  a  r<'snlt,  a  smooth  surface  and  ;in  opi  n  pa>.-aLre.  A 
reeoatinu'  I'f  new  mueons  memliraiie  (|uiekly  foilnw-:.  The  aeconi- 
Ijanyinj:  microscopical  section  was  t;iken  from  n  -pur  iinuned  in  this 
way  from  a  irentleman,  ajred  TiS,  who  had  lieeu  siill'crin<j;  from  na-al 
Oijstrnction  for  thirty  years.  Calcilieation  had  ciijnmenced  in  the 
liy])ertrophied  cartilaue  (Fig.  •'"•■^/. 

Other  operatiirs  advocate  the  use  of  luirrs  operated  h}  a  denial 
engine  or  clectrninotor.  lloHunok  Cuiti.'.-  has  invented  a  series  of 
.«mall  iK'phincs  adapted  for  the  loinoval  of  this  se|)tal  outgrowtli. 
These  are  ingenions,  Imt  unless  very  skillfully  used  they  may  fail  to 
leave  the  perfectly  smooth  surface  which  is  so  dcsirahle  and  which 
can  he  .-ciiired  hy  the  use  <if  the  saw.  The  latter  instrument  is 
usually  operated  hy  hand,  hut  can  also  lie  attached  to  an  electromotor 
machine. 

To  save  the  mucous  memhrane,  Fletcher  Ingals  make.-,  an  in- 
cisiiui  aloiijr  the  lower  maririn  of  the  spur,  dissects  np  the  mucosa, 
and,  retracting  it  to  free  operation,  excises  the  pri\jeclinLr  carlilage. 
The  mucf)us  memhrane  is  then  drawn  down  and  sninred  to  its  foinier 
attachment.  Hy  this  means  the  original  mucosa  is  retained  in  it.s 
entirety.     Kyle   follows  a  similar  plan   in  curvature  of  the  se|)lum. 

Loch  advocates  the  use  of  sharp,  highly-tempered  curettes,  par- 
ticularly in  cases  where  saws  cannot  he  used. 

Cheval,  liallinger,  Casselherry,  and  other  recent  writers  havt; 
used  electrolvsis  with  good  results  in  removing  cartilaginous  spurs. 


84 


DISKASKS    OK    Tin;    NASAL    I'ASSAUKS. 


T)io  latter  I'ound  clcttrdiiiotor  force  of  11  to  14  volts  necessary,  with 
a  current-strength  of  rrnni  1")  to  40  niilliamperes,  according  to  tlie 
amount  of  resistance  found  in  the  spur  operated  upon.  The  time 
for  each  sitting  was  from  live  to  eight  minutes,  to  he  repeated  two 
or  three  times  at  inttTViil.^  (if  x-vcral  days. 

Jn  some  cases  al'tt  r  I'diioving  a  spur  or  ridge,  at  the  hase  of  a 


Fig.  52. — Section  of  ciiililiiginons  spur  from  the  nasal  septum  (25 
diameters),  a.  Stratified  eiliated  epitlieli\im.  I),  Stratified  squammis  0|)i- 
tlu'liiini.  r.  (ilandsi.  rf.  Connective-tissue  layer,  r,  Cartilaginous  ai)ur.  the 
lower,  shaded  portion  undergoing  calcifieation.  (Author's  specimen  by 
Bensley.) 

convex  curvature.  I  liave  corrected  the  curve  above  by  the  use  of  a 
silver  tube.  If  the  instrument  is  worn  for  a  few  weeks  or  months, 
the  cartilage,  being  pressed  by  it  into  the  normal  position,  will  re- 
main so  with  but  little  subsequent  deflection,  the  adjustment  being 


DDIOUMITIES   OF   TUE   NASAL   SEI'Tl  M. 


^.) 


reiKlci('(l  cai^y  by  tlie  ciitiing  awiiy  of  the  :=i)iir  or  ridgo  base.  The 
advantage  oi'  silver  tubori  lies  in  their  lightne&s,  aseptie  cliaraetcr, 
smooth  surface  inside  and  out,  and  the  fact  that  a  silversmith  can 
form  one  to  suit  each  special  case.  Tiie  open  tulie  enables  the  patient 
to  breathe  through  it.  A  small  bulge  jiliui'd  cm  tiie  outer  wall  will 
secure  its  retention,  and  tln!  patient  can  soon  learn  to  remove  it  daily 
for  cleansing  ])urposes  and  return  it  to  its  position  (I'igs.  i'ui  and  51). 
Tubes  of  this  kind  are  also  uselul  in  cases  of  severe  traunuition. 
in  which  either  of  the  antciior  nasal  pa^snges  has  been  destroyed. 
In  one  case  which  I  reported  to  the  laryngological  section  of  the 
American  Medical  Association  at  San  Francisco  several  years  ago,  the 


'!■■ 


Latciiil  view. 


isrcll    fldlll    al)OVl\ 


Viff.  ry.i 


II 


Liitoral  view.  Seen  frmn  aliovc. 

Fig.  .'54. 

Silver  tubos  for  septal  deformity. 


mucous  membrane  of  the  car+'^-'ginous  portion  of  the  left  nasal  pas- 
sage bad  been  entirely  destroyed,  the  anterior  ends  of  the  middle  and 
inferior  turbinaleds  being  firmly  united  to  the  se|)tum.  1  cut  a  new 
openinir  throuirh  the  fibrous  cicatricial  tissue  and  bad  the  tube  (I'ig. 
T),?)  made  to  be  passed  into  it.  Tlie  front  end  was  half  a  centimetre 
from  the  anterior  naris  and  invisible.  The  arch  being  upward  pre- 
vented mucus  from  gravitating  into  the  tid>e,  and  it  enabled  the 
patient  to  breathe  freely  through  it.  The  bulge  kept  it  in  position. 
The  wearer  takes  it  out  every  morning  as  a  matter  of  toilet,  and  at 
once  returns  it.  He  has  worn  it  now  for  five  years.  Since  the  opera- 
tion he  has  resumed  his  position  as  leading  tenor  in  a  large  church. 


m 


Hi 


■f.v 


8() 


UlSKASKS    OF   Tllli    NASAL    TASSAGEH. 


^W^ 


III'' 

ill' 


which  he  had  been  compelled  previously  to  resign,  on  account  of 
j)ost-nasal  catan-h  caused  by  the  unilateral  stenosis.  1  expect  in  time 
the  artificial  opening  will  remain  permanent,  without  the  use  of  the 
instrument. 

In  a  somewhat  similar  case,  in  which  traumatic  adiiesions  had 
formed  from  the  lioor  to  the  middle  meatus,  Myles  succeeded  in  a 
(liU'orcnt  way.  Ifc  trephined  along  the  iloor  of  the  nose,  and  then 
iii.-ertcd  a  rubber  tube.  This  was  retained  until  a  new  passage  had 
formed.  The  subsequent  operation  was  the  removal  of  the  cicatricial 
tissues  l)ctw('('n  the  superior  meatus  and  the  new  opening. 

When  till'  enlargement  would  iudicati'  increa>:cd  Ictigtli  or  height 
of  septum,  Arthur  Watson  advocates  removing  an  elliptical  or  wedge- 
shaped  portion,  as  the  ca?e  might  requiix',  cutting  through  the  se])- 
tuni,  but  leaving  the  mucous  meinlirane  on  the  opposite  side  entire. 
Cutting  forceps  could  be  used  if  retpiiicd.  The  piiit-  iirc  then  |>ressed 
into  position  and  held  by  pins,  the  ends  of  {Uc  pins  liciiig  piidiled  to 


lU'cvi'iit   ulcirjition.     'J'hey   may 


in   position   fur  three  weeks, 


when  union  uili  Ite  aeconi|ilislied  witii  cure  of  the  deformity.  The 
sp(d<i'sliave  is  also  used  f(jr  the  rciuovai  of  ])rojecting  nodules  and 
sj)urs  upon  the  septum,  giving,  in  many  instances,  a  satisfactory  re- 
sult. 

.\s  a  rule.  I  tbiidv  the  most  widely  useful  of  all  is  the  saw  opera- 
lion,  it  will  fulfill  the  requirenu'ids  of  the  majority  of  ciiMs.  In  the 
first  place,  a  ">i-  or  4-per-cent.  sidulion  of  cocaine  should  be  thrown 
into  the  nostril  by  an  atomizer.  Then  a  stronger  solution,  of  10  or 
15  per  (lilt.  -Iioiild  he  iipjilicd  by  a  curved  cotton-ludder  to  the  sep- 
tum. This  iniiy  be  re|teated  two  nv  three  times.  In  live  to  eight 
minutes  the  parts  are  ready  for  operation.  Two  saws  are  required; 
one  with  teeth  on  the  upper  i'^lixc.  the  otlier  with  teeth  on  the  lower. 
It  is  always  better  also  to  have  the  handle  of  the  saw  at  an  angle  of 
forty-live  degrei's  to  tlie  central  line  of  the  shaft,  'i'he  lower  lilade 
is  insei'tid  first  and  ttie  cutting  is  always  done  parallel  to  the  axis 
(d"  the  cpfiiiii.  Then  the  cut  downward  with  the  upper  sa.v  is  made 
to  mi'i't  exactly  with  the  inferior  incision.  'i\)  ]H'rform  the  opera- 
tion reipiires  a  good  s])ecidnin  and  a  good  reflected  light.  The  word- 
ing of  the  operation  is  sim]de.  but.  to  do  it  successfully,  care  and 
])atience  are  reijuired.  When  the  exostosis  is  large  and  bard,  the 
operation  nuiy  be  tedious,  necessitating  several  stop]iages  before  com- 
pletion, in  order  to  arrest  or  remove  the  blood.  There  is  also  danger 
from  fainlncss,  diuj  to  the  action  of  the  cocaine  conddned  witli  tlie 


DKKOaMlTlKS    or    THE    NASAL    SEl'JTM. 


87 


shock  of  the  ojRTiition.  'J'hcTc  is  likewise  diuij^or  of  flitting  throiigli 
tliu  tfcptimi,  ami,  althuuirh  this  was  tiio  approved  ineliiotl  of  ti'cat- 
niont  at  oiio  time  for  tlie  relief  of  one-sided  stenosis,  it  is  something 
which  the  can'ful  surgeon  wi.-hes  to  avoid  imw .  With  judicious 
management,  it  is  an  accident  of  e;.eeedingly  rare  occurrence. 

J.ittle  after-lieatment  is  necessary.  Jf  liieinorrhage  arising  from 
the  operation  does  imt  at  on^e  sui-side,  it  is  better  to  pack  the  blecd- 
ing-sjiot  with  cotton  tampons.  These  may  he  left  in  for  one,  two, 
or  evi'u  three  days  witiiout  producing  any  evil  elfect.  They  may 
be  renewed  entindy  or  in  [)art  at  any  time,  as  llie  tendency  to  bleed- 
ing may  direct.  One  uf  the  main  objects  after  operation  is  to  pre- 
vent the  anterior  part  of  the  cut  surface  from  beconung  dry,  as  any 
liard  crust  forming  upon  it  would  retard  the  proces.',  of  healing. 
'J'o  avoid  this  the  patient  should  ))e  directed  to  aj)ply  vasclin  to  the 
septum  several  times  a  day.  This  should  be  done  particularly  before 
retiring  for  the  night. 

In  the  majority  of  ca?es  a  few  weeks  will  sullice  to  recoat  the 
raw  surface  with  mucous  membrane.  It  gradually  forms  from  the 
border-line,  usually  covering  the  wound  without  leaving  any  cicatrix 
to  nuirk  the  site  of  the  operation. 

Occasionally  unpleasant  sequels  follow  operations  upon  the  nasal 
septum:  such  as  severe  luemorrhage,  which  may  recur  at  intervals 
for  several  days  before  it  entirely  ceases;  formation  of  synechia; 
between  the  septum  and  the  inferior  turbinated;  and  tlie  production 
of  excessive  granulations.  Careful  treatment  will  avoid  or  at  least 
overcome  all  these  dilhculties.  ^"ery  rarely  even  a  septal  abscess  has 
been  the  result  of  septal  operation.  Ledernuui  recently  reported  a 
case  of  this  kind.  It  occurred  in  a  young  woman  aged  22.  Ordi- 
nary antisejitic  precautions  were  taken.  The  first  saw  operation  upon 
an  extcTisive  ecchondrosis  gave  some  relief  and  healed  well  in  two 
weeks.  A  second  operation  to  complete  tlie  removal  of  a  remaining 
exostosis  was  tlien  done.  In  four  days  an  abscess  of  the  septum  com- 
menced to  form  and  had  to  be  lanced  several  times  iK'fore  it  entirely 
healed. 

In  dealing  with  these  cases  it  is  not  tlu>  operative,  but  the  post- 
operative, treatment  that  I  have  usually  found  the  most  troublesome. 
By  saw  or  knife,  drill  or  scissoi-s,  or  curette,  single  or  combined,  the 
projecting  spur  or  ridge  might  be  removed;  synechia'  connecting  the 
turbinated  with  the  septum  could  be  excised;  or  a  partial  turbincctomy 
when  necessary  might  be  performed;   but  to  procure  smooth  equal)le 


in 


88 


i)isi:asi;s  ok  thk  xasal  I'assaoes. 


M 


support  for  tlu'  iiuisud  tissues  duriiij:  tln'  procop?  of  hcalin^r  has  been 
a  mucli  harflor  matter. 

1  think  tliat  ruhher  splints,  niaih'  as  Lake  advises,  from  thick 
rubber  sheetinjr,  do  bettor  work  than  anylliing  else  we  have  at  our  com- 
mand for  many  of  tliosc  cases.  Their  surfaces  are  smootli.  C'om|)res.^ible, 
and  ehistic;  tliey  can  be  readily  cut  to  the  required  shape,  and  they  can 
be  obtained  of  any  thickness  we  desire. 

.\rter  cncaini/.ini:  the  ]iarts  and  coating  the  plug  with  va.selin  it 
can  readily  be  placed  in  position.  Once  in,  it  will  not  only  retain  its 
])la(e.  but  l>y  elastic  pressure  give  a  smooth  and  even  fjupjxirt  to  the 
raw  surface  to  which  it  is  applied,  as  well  as  prevent  that  profuse 
granulation  which  otherwise  would  sometimes  occur.  At  the  same 
tiuie  it  does  not  retard  the  gradiuil  exteii-ion  of  the  im'vv  mucous  mem- 
l)rane,  while  it  molds  the  tissues  into  a  smooth  and  regular  form. 

The  stiir  plial)le  ruhlier,  although  TU)t  so  hard  on  the  surface,  nor 
possessing  the  j)oIisli  of  the  vulcanite,  is  proliablv  Just  as  imperviouh 
to  bacterial  invasion.  Souu'tinus,  however,  after  prolonired  u-^e  it  will 
accpiire  a  peculiar,  unpleasant  odor,  in  part  arisiug-  from  the  rubber 
itself.  In  these  cases  new  splints  or  tajupons  should  be  substituted  for 
the  old  (Uies. 

The  lenglli  ('!'  time  during  wliicli  the  splint  will  rcipiirc  to  be 
worn  will  depend  upiui  the  particular  condition  of  each  case.  On 
])lacing  it  in  ]iosition  it  may  usually  be  allowed  to  remain  in  from  two 
or  three  days  to  a  week  witliout  removal.  The  chink  above  the  splint 
can  be  washed  out  each  day  with  a  weak  sju-ay  of  cocaine,  followed 
by  one  of  albolene;  so  that  there  is  no  danger  of  retention  of  septic 
secretions.  Quite  frequently,  too,  when  once  removed,  there  will  be 
no  necessity  for  a  replacemenl  of  the  tampon. 


t 


CHAPTER  XIT. 


DISTORTION'  OF  THE  COLl'.MNAl!  CAKTILAGE. 


' 


BoswouTH  was  (lie  firt^t  to  draw  attention  io  the  dislocation  of 
this  hddy.  Tn  hoth  the  ease:?  of  which  he  iravc  a  detailed  report  the 
disjilaceiiienl  was  cxtrciiic.  >eriMii>ly  iiiii  il'crir.u'  "ill)  respiration 
thi'niiu;h  the  e()rresp()iulin<;  naris;  ami  in  each,  iii  (Hilcr  id  i^ive  ade- 
([iiate  relief,  conijdete  removal  ni'  the  lartilaue  hecaiiie  necessary.  A 
small  incision  was  made  alnng  the  axis  of  the  cartilage  and  the  car- 
tilage itself  removed  through  the  opening.  Then  the  redundant  por- 
tion of  the  nuicons  niemln'aiie  was  excised  and  the  edges  united  with 
fine  sutures.     The  result  was  satisfactory  in  each  case. 

Although  extreme  caM's  are  rare,  dis]ilacement  of  the  columnar 
cartilage,  to  a  more  or  less  degree,  is  not  hy  any  means  infrequent. 

'J'he  columnar  cartilage  is  a  little  column  of  cartilage  placed 
directly  anterior  and  inferior  to  the  triangular  cartilage  of  the  sep- 
tum, it  is  loosely  attached  to  it  hy  connective  tissue  in  the  centre 
and  mucous  memhrane  on  the  two  sides,  a  is  very  movahlo,  covered 
hy   integument,  and   foiin~   the  septal   division  of  the  two  anterior 


nares. 


The  anterior  end,  placed  just  hcneath  the  tiji  of  the  nose,  is 
almost  invariahly  in  position.  It  is  the  lower,  or  ]iosterior,  end  that 
so  fretpiently  hecomes  distorted;  and,  heing  displaced  to  one  side, 
may  have  the  efTect  of  almost  comi)letely  closing  that  nostril. 

The  cause  of  the  distortion  is  somewhat  ohscure;  as  displace- 
ment of  the  septum  in  infancy  is  almost  unknown,  displacement  of 
the  cartilage  at  that  early  age  would  he  even  more  rare.  The  proh- 
ability  is  that  the  distortion  is  in  every  instance  acquired.  It  may 
owe  its  origin  to  i)icking  the  opposite  nostril  or  placing  the  finger 
in  the  wider  cavity,  to  which  some  children  are  addicted.  From 
personal  observation  I  believe,  too,  that  it  sometimes  arises  from  the 
habit,  acquired  during  childhood  and  practiced  on  through  life,  of 
invariably  twisting  the  nose  over  to  one  side  when  using  the  pocket- 
liandkerchief. 

One  of  my  earliest  cases  was  a  gentleman  of  40  years.    He  had 

(89) 


90 


DISKASKS    OF   TJIK    NASAL    I'ASSAUKS. 


a  good  (leal  of  septal  deformity,  but  the  columnar  eaitila<;f  wa.s  the 
worst  of  all.  It  was  doubled  on  itself  and  almost  filled  the  right 
naris.  I  observed  his  use  of  tiie  Inndkerchief,  and  he  informed  me 
that  he  had  always  pulled  the  nose  over  to  the  right  wlieii  wiping 
that  organ. 

Treatment.— Ill  cxlrcme  cases  IJosworth's  method  would  prob- 
ably be  the  best  tiiat  could  be  followed.  In  milder  cases,  however, 
the  treatment  might  be  materially  modified,  and,  allhougb.  I  have 
operated  on  a  number  of  cases,  I  have  never  found  entire  rennival 
of  the  cartilage  necessary. 

The  treatment  consisted,  first,  in  producing  local  anaesthesia  by 
injecting  a  few  drops  of  r)-per-cent.  solution  of  cocaine  beneath  the 
cuticle  of  the  septum,  followed  by  the  local  apjilication  of  a  stronger 
solution  to  the  mucous  menil>rane.  Then,  by  ])rcssing  the  skin  of 
the  septum  toward  the  opposite  nostril  the  cuticle  of  the  cartilage 
was  put  on  the  stretch.  Thereupon,  with  a  sharp,  nari'ow-bladed 
knife,  the  prominent  portion,  membrane  and  cartilage  together,  was 
split  off  from  end  to  end.  By  this  means  a  ])ortion  of  the  cartilage 
was  in  each  case  saved.  There  was  no  redundant  mucous  membrane 
left,  and  that  jjortion  which  had  been  pressed  f)n  the  stretch  over  to 
the  opposite  nostril  slipped  back,  in  great  measure,  over  the  raw 
surface  and  covered  it.  Sutures  were  not  required,  and  in  a  few 
days  by  simple  vaselin  dressing  tlie  wound  healed,  leaving  the  nos- 
tril patulous  and  the  naris  almost  in  a  normal  condition. 


II  ' 


1 

'I 


CIIAPTKH  XIIT. 


rEiiror.ATJONS  of  thk  s^ki'tum. 


This  usually  occurs  throui^h  the  triangular  curlilaj^c;  sometimes, 
though  rari'iy,  tlirnujjh  the  vomer.  When  in  the  latter  situation,  it 
is  believed  to  l)c  the  result  of  syjiliilis,  serol'ula.  or  nialijrnant  disease, 
or  else  of  traumation.  Perforations  of  liie  cartilage  are  u.-ualiy  of 
local  origin;  and,  as  the  majority  of  cases  occur  during  the  hiter 
years  of  cliildhood,  they  are  probably  the  result  of  digital  erosions, 
made  during  that  period,  when  purulent  rhinitis  is  being  gradually 
transformed  into  atrophic  disease.  1  look  u])on  this  as  probal)le  from 
the  fact  that  the  nuijority  of  cases  that  have  come  under  my  obser- 
vation have  been  atrophic  cases,  and  yet  in  wliich  the  patients  could 
not  tell  when  the  perforation  had  taken   jdace. 

Another  cause  in  the  scrofulous  subject  is  the  projection  of  the 
triangular  cartilage  into  one  nostril.  In  this  case  dust-laden  air  re- 
peatedly inhaled  im])inges  upon  the  prominent  spot,  gradually  pro- 
ducing erosion  of  the  mucous  membrane  and  cartilage.  r)y  and  by 
crusts  form;  and  the  removal  of  these  crusts  leaves  an  ulcerated  sur- 
face which  continues  to  develop  until  perforation  is  the  result. 

Bosworth  looks  upon  the  erosion  and  ])erforation  as  an  efTect  of 
Nature  to  remove  the  obstructive  lesion,  and  the  result  as  beneficial 
rather  than  injurious  to  the  health  of  the  patient. 

Treatment. — In  this  matter  very  little  is  required.  The  main 
point  is  to  keep  the  perforation  free  from  accumulation  of  secretions, 
and  not  to  allow  crusts  to  form  upon  its  margins.  If  the  outline  is 
irregular  and  jagged,  this  can  be  trimmed  to  produce  an  even  sur- 
face, and,  as  l^ishop  says,  if  the  perforation  produces  a  whistling 
sound  in  breathing,  the  shape  can  be  altered  to  allow  the  air  to 
pass  through  the  opening  less  noisily.  Sometimes  the  posterior  half 
of  the  opening  will  become  thick  and  granular,  rendering  that  part 
of  the  septum  unusually  thick  and  with  a  tendency  to  bleed  ujion 
pressure.  In  this  case  the  parts  can  be  reduced  by  knife  or  cautery 
operation  to  the  respiratory  advantage  of  the  patiiuit. 

Accidental  perforation  of  the  bony  septum  during  operation  for 
the  removal  of  spurs,  etc.,  will  sometimes  produce  severe  shock;   but 

(91) 


fl 

i:    tk 

•  i\     ■iml 

II I 


1)2 


DISKASKS    Ol-    TUK    NASAI.    I'ASSAUKS. 


I  lit'  iiflcr-i'tlVits  iiiv  not  vt'i'v  sLTiouri.  Still,  it  is  tlic  tluty  of  every  sur- 
f,'con  to  do  all  that  he  car.  lo  avoid  an  accident  of  this  kind.  French 
perforates  the  sei)tuni  to  improve  the  breathin^^-spaee  when  necessary. 
Wright  insists  upon  proper  antiseptic  treatment  before  and  after  all 
operative  work  ii|)on  the  nose,  with  which  all  surgeons,  no  doubt, 
agree. 

Abscess  of  the  septum  is  an  exicedingly  rare  disease,  but  wiicn 
il  does  occur  it  is  usually  the  result  of  traunuilism,  and  should  bo 
treated  upon  ordinary,  antiseptic,  surgical  principles. 

riceration  of  ihe  sejitum.  a])art  from  its  occurrence  as  a  i)relude 
to  jierforation,  is  also  a  vi  ly  rare  disease.  Still,  in  scrofulous  and  syj)!)- 
ilitic  subjects  il  docs  sometimes  occur.  Likewise  in  young  children, 
victims  of  Ascaris  rcniiicularis,  itt-hing  of  the  nose  may  be  produced 
by  reflex  irritation,  leading  to  picking  and  scratching  of  that  organ 
until  septal  ulceration  is  the  result.  In  all  these  cases  systemic  as  well 
jis  local  treatment  may  be  icijuired  to  cure  the  disi'ase. 


li 


!  ; 


It' 


'1 

I 

.1 

:. 

i 

1 

., 

il 


f< 


i    ■ 


C'llAlTK't  XIV. 
HAY  FKVKU,  OU  VASUMUTOK  lailMllS. 

JiosTOCK,  of  Luiulon,  in  ]81!)  was  tlu;  liol  amoiiy  uiodtini  writcis 
In  dniw  attention  to  tliis  disease,  alllii>u<f|i  it  iiad  heen  reeoi^iiized  in 
an  indefinite  manner  by  iihysieian.s  U>v  the  previous  two  centiirie,*. 
It  was  observed  by  liim  to  occur  during  tiie  summer  months  ,iion;i 
persons  worlcing  in  Die  vicinity  of  jiew-mown  hay.  l''rom  iliis  Imt 
it  derived  the  name  which  it  still  t)ears.  That  there  are  two  varieties 
of  this  disease,  one  occurrin<;  in  June  ami  the  other  in  .\uuust,  and 
that  till'  symptoms  may  be  provoked  by  emanations  from  a  multitude 
of  substances,  have  not  militated  against  the  title,  inasmuch  as  the 
symptoms  are  in  all  cases  alike.- 

J  lay  fever  may  be  defined  as  a  periodic  disea.se  occurring  an- 
nually at  a  fixed  period  of  the  year,  an  I  attended  by  intense  liyper- 
sensitiveness  and  hypersecretion  from  the  mucous  membrane  of  the 
nose,  eyes,  and  throat. 

Pathology. — The  pathological  changes  occurring  in  this  disease 
have  long  been  the  subject  of  careful  investigation.  During  the 
most  aggravated  exacerbation  there  is  little,  if  any,  rise  in  tempera- 
ture. There  is  no  jirevious  chill.  There  is  no  febrile  action,  and  yet 
the  wliole  system  is  affected  by  the  violence  and  suddenness  of  the 
explosion.  Suddenly,  and  without  warning,  a  vasomotor  i)aresis  is 
induced.  The  blood-vessels  and  venous  sinu.^es  of  the  turbinateds 
become  relaxed  and  surcharged  with  blood.  There  is  complete  pa- 
ralysis of  the  nerves  which  control  exosmosis,  and  the  serum  is  tran- 
suded freely  from  all  the  pores  of  the  mucosa. 

The  length  of  time  during  which  the  veins  remain  in  this  state 
of  dilatation  depends,  according  to  some  writers,  upon  the  ([uantity 
of  irritant  present  within  the  nasal  passages.  The  exciting  raii.se  being 
over,  the  ve.-j.sels  contract,  the  exudation  ceases,  and  the  parts  return 
to  their  normal  ((111(1111011,  the  nnieo.-a  relainiiig  only  an  ana'tnic 
apjiea  ranee. 

It  is  generally  believed  now  that  this  disease  is  essentially  a  neu- 
rosis.     It   affects   chiefly    jiersons   of  a    nervou.-    temperament.      The 


y 


':  !( 


,m 


■>', 


i::i 


III! 


!)l 


i»isi:.\si;s  ni    iiii;  s.\s\t,  I'assaoks. 


luTvo  iiirciiiil  iirc  llic  >viii|i;iilici  ic  iiiid  liii:t'iiiiiiii>.  which  idiiiiol  the 

VllSdiiinlnr  .sVsli  111  (if  the  lliisc.     .Idhll   .Mili'Kcll/.ii'  lirlirvcs  it   to  he:    "'A 
(lisdiilricd  rimctiniial  iittivitv  nl'  tlic  nervous  ccntn's";   .loiil,  l.flhiivo. 


ami 


i(  r.«  that   it  i-  a  irih'v  neurosis;    Dehivaii  that  unilerlviii''  tliat 


iieiii(i.-i>  ihi  ]•(•  are  ''eiieral  or  diatlietic  coiulilioi 


IS    Wll 


ich    leliil    to   ih 


prndiii  tioii  of  the  disease.  Hence  it  is  jjn'tty  fieiierally  looked  upon 
as  a  timet ioiial  neurosis,  l)Ut,  like  other  functional  neuroses,  it  never 
destroys  lite,  and  the  neuropath(do,i.'ist  in  eonseiinenee  is  d(^i)rivi'd  of 
the  opportunity  of  iiost-iiiorteni  iiivestijiation. 

Etiology. — Misliop  presents  the  following'  as  a  summary  of  our 
present  knowlcd.ire  ni)on  this  ])ranch  of  the  subject:  "Tlius,  it  ap- 
pears, from  the  manner  in  whicli  paroxysms  of  hay  fev{>r  arc  started 
and  developed,  that  there  are  three  ecuiditions  njion  which  the  ex- 
istence of  the  disease  depend.-:  1.  Alinornially-suseeptihlo  nerve- 
centres,  l*.  Hypor.Tsthcsia  of  the  peripheral  termini  of  the  sensory 
nerves.  3.  The  presence  of  one  of  a  larire  variety  of  irritating  ajxents. 
Kxcludc  one  of  these  conditions,  and  the  paroxysms  are  prevented. 
Allay  the  susee])til)ility  of  the  nervous  centres  l)y  certain  central 
sedatives  and  an  attack  is  averted  or  arrested,  ana'sthetize  t'u^  nerv- 
ous supply  of  the  oversensitive  areas  and  the  result  is  the  same.  He- 
move  the  patient  beyond  the  reach  of  exciting  causes  and  he  is  as 
comfortable  as  any  mortal."' 

Bosworth  also  gives  three  conditions  as  essential  to  the  produc- 
tion of  an  attack  of  hay  fever,  l)ut  they  differ  somewhat  from 
Bishop's,  and  they  are  given  in  an  inverse  order.  They  are:  "1.  The 
presence  of  pollen  in  the  air.  2.  A  neurotic  habit.  3.  .\  morbid  con- 
dition of  the  nasal  mucous  membrane." 

1.  "Abnormally-susceptible  nerve-centres"  and  the  "neurotic 
habit"  may  be  taken  as  essentially  the  same  thing,  and  is  probably 
the  primary  cause  of  the  disease.  Witliout  its  presence,  to  cominenco 
with,  hay  fever  would  be  an  impossible  thing.  What  the  essential 
pathological  condition  is  that  we  term  the  neurotic  element  would 
be  difficult  to  ox])lain.  Still,  it  is  well  known  from  extensive  clinical 
examination  of  hay-fever  subjects  that  the  family  history,  in  a 
majority  of  instances,  justifies  the  opinion  of  the  presence  of  ab- 
normally-sensitive nerve-centres  in  other  members  of  the  family  like- 
wise, though  it  may  not  liave  been  manifested  in  the  same  way. 

2.  ITy])er{rsthesia  of  the  jieripheral  termini  of  the  sensory  nerves 
may  arise  from  dilTerent  causes:  such  as  a  morbid  condition  of  cer- 
tain  parts   of   the   nasal   mucosa,   hypersensitive    areas,   obstructive 


1 

V 


WAV  i"i;vi:i(,  Oil  vasomotor  hiiinitis. 


95 


lofinns  of  tlio  sopttim  or  turltiiiiitfflH,  or  llio  pressure  of  overgrowth 
upon  adjoiTiinj^  lissiic-j. 

',h  The  presence  of  nii  irritiitinj,'  ngent  will  include  Hosworlh's 
first  ciius(>:  the  pollen-in-thc-;iir  theory,  \r,\<v(\  ou  iilacklev's  investi- 
gations. 'I'liis  <ientlonian  was  himself  the  subject  of  hay  fever, 
usually  coinin.u;  on  in  Juno.  With  the  idea  that  pollm,  lloating  in 
the  atmosphere,  mi;,dit  he  the  cause  of  it,  he  undertook  a  series  of 
experiments  to  asceiiain  the  truth  of  his  theory.  His  most  success- 
ful experiments  were  hy  the  \\<t'  of  a  small  disk  of  iilass,  coated  with 
glycerin  and  suspended  in  the  air.  He  found  tluit  in  twenty-four 
hours,  in  the  hciiinning  of  June,  hut  a  small  numlier  of  grains  of 
pollen  would  heconie  attached  to  the  disk.  I>y  about  the  tenth  they 
would  have  increased  ahout  tcnf(dd,  and  the  hay  fever  wnidd  have 
eoniincTU-ed.  Inside  the  next  three  weeks  the  grains  of  pollen  would 
agaiti  he  tripled,  with  niaiknl  iiurease  in  ilie  severity  of  the  symp- 
toms, from  this  time  forward  tlie  pollen,  and  with  it  the  hay  fever, 
W(udd  -uliside.  until  hy  .\ugust  Isj  imth  would  disappear.  If  h(>avy 
rains  occurred  during  the  prevalence  (d'  pollen,  they  would  tempo- 
rarily dimiiiisli  in  nuudier.  aiul  the  symptoms  for  tlie  time  l)eing 
would  also  suhside.  while  hoth  would  return  as  soon  as  there  was  a 
chance  for  the  grains  to  rise  acain  iji  the  air. 

Isxperience.  liowevcr,  does  not  condne  the  local  irritant  by  any 
means  to  pollen.  AVe  tind  many  of  our  cases  residents  of  our  large 
cities,  where  little  pollen  can  be  possible  in  the  air  of  respiration;  no 
doubt  the  coincidence  of  the  prevalence  of  hay  fever  at  the  period  of 
the  year  when  the  atmosphere  is  most  loaded  with  it  would  indicate 
a  causative  relatioji  as  existing  between  the  two.  But  there  are  many 
irritants,  ])hysical  and  even  mental,  which  may  induce  an  attack. 
The  presence  of  feathers,  odor  of  aninmls,  ])erfumes;  hot,  impure  air; 
sudden  change  of  temjierature,  mental  worry,  even  exposure  of  the 
spinal  column  to  the  air  have  all  induced  exacerbations  of  the  dis- 
ease. So  true  is  this  that  a  violent  attack  has  been  known  to  be  in- 
duced in  an  old  hay-fever  patient  by  merely  gazing  upon  a  })icture  of 
a  field  of  new-mown  hay. 

Although  we  can  understand  the  jircsence  of  an  irritant  to  l)o 
the  original  exciting  cause  of  the  first  attack,  yet  it  is  diHicult  to  bc- 
]i':'ve  that  each  exacerbation  is  dependent  upon  the  same  exciting 
cause.  For  instance,  a  patient,  after  a  paroxysm  of  sneezing,  and 
profuse  flow  of  serum  from  +he  nostrils,  and  profound  tickling  irri- 
tation of  the  palate,  will  retire  to  hed  under  a  sense  of  complete  relief. 


iii 


1} 


if 


I 


r'  :w\ 


(■■J  .ft 

ih'  fit 


"1 


Im;  |)|si;.\si:s  or  riii;  n asai,  I'assa(ik.s. 

Kv(i>tliiii;,'  is  (liiiic  h)  Miiihr  lliu  air  ol'  tiiu  rnom  pini'  imd  t'icf  I'min 
irritiitil>.  'I'lic  iii;;lil  is  hot  ami  he  can  hrar  iiothiii;^  but  a  .sheet  over 
him.  1  am  s|ieal\iii;;  ol'  a  east;  wilh  uliicli  I  am  perfeetly  i'amihar. 
'I'iiat  |ialiiiit  kiiowfi  by  e.vperieiiee  thai  il'  he  lies  perfeetly  still  ii|»on 
his  hack,  wilii  all  his  body,  hands,  and  I'eet  covered  with  the'  sheet. 
he  will  he  able  to  lie  for  hours,  and  even  tu  sleep,  btd'ore  another  e.\- 
aeerbalioM  will  appear.  Iiut.  warm  as  it  is,  if  hi;  e.\pose.s  a  foot  or 
a  hand  fnmi  beneath  the  co\eiiii^'.  he  knows  that  another  attack 
of  biioezinj?  will  come  on  at  once,  and  lli.it  he  will  saturate  two  or 
three  more  handkerehii'fs  before  it  subsides. 

What  has  pollen,  or  dusi,  or  foul  air.  or  feathers,  or  animal  o(h»r 
lo  do  with   this? 

J  know  a  case,  alu,  of  a  ^^'nileman  who  has  a  periodic  attack 
of  hay  fever  for  a  month  every  year,  eonimencin;,'  near  the  end  of 
Au^usl.  Ili.s  worst  exacerbations  occur  durin;^  the  iii«rht-time;  but 
he  can  j;(i  daily  and  sit  to  ri'ad  in  a  larjre  |)nblic  garden,  (illcd  with 
llower-bed,->  and  exotics,  without  feeling  any  inconvenience  from  the 
jiolleu  rising  from  them. 

I  do  not  wish  in  any  way  to  dei)recate  the  importance  of  poUon 
or  any  other  irritant  us  e.xeiting  eause.s  of  this  disease,  but  1  do  wish 
to  emphasize  the  fact,  that  there  must  be  something  inherent  in  the 
system,  when  the  disea.se  has  once  developed,  which  itself  j)roduees 
these  periodic  explosions,  from  which  hay-fever  patients  so  severely 
siifTer. 

Shaw  Tyrrell,  of  Toronto,  and  IJisliop,  of  Chicago,  have  for 
years,  independently  of  each  other,  been  advoraliiig  a  new  theory  as 
to  the  cause  of  hay  fever.  They  believe  that  to  some  extent  it  is 
caused  by  the  presence  of  an  abnormal  amount  of  uric  acid  in  the 
blood.  According  to  this  theory,  the  fonnation  and  retention  of  uric 
acid  in  the  tissues  docs  not  produce  hay  fever,  but  the  presence  of 
uric  acid  in  the  blood  does. 

'J"he  majority  of  cases  of  this  di';ea.se  occur  between,  the  ages  of 
ten  and  forty  years,  and,  in  accordance  with  Bosworth's  statistics,  the 
majority,  in  the  ratio  of  two  to  one,  are  nuiles. 

Another  important  point,  u]ion  which  all  writers  agree,  is  that  it 
is  a  disea.se  incident  to  the  educated  cla.sses  and  sedentary  life.  This 
is  what  we  might  expect  when  we  remember  that  hay  fever  is  so 
largely  a  neurosis. 

Symptomatology. — Slight  premonitory  symptoms  in  the  form  of 
tingling  or  itcdiing  of  the  eyelids,  nasal  passages,  or  soft  palate  may 


IIAV     IK.VKH,    n|{    VASO.VtOIOK    l(IIIMII>. 


n; 


|tros('iil  tliciiisclvo  f(ir  tliiv.-  licfurc  tlu'  iliscjisc  fully  ilfVi-lops.  'riicn 
hpiisiiHidic  riilliit'Sn  dl'  tlic  nose  will  occur,  -ncc/in};  will  coiiir  on,  iiml 
the  c<)n{,'csti<iii  will  Iiml  rclicl'  in  |»i(»riist;  wntcry  diMliar^c.  'i'lio  c.vi'- 
lids  and  cyclmlls  liccniiic  cnii;;c.-il('d,  and  cuiiiniis  lacrymatiDii  adds  In 
the  j,aiicral  di,«lics,-.  'I'lic  dixhar^fcs  arc  oltcii  |ii'(il'ii.-c  and  liic  .■.ncc/- 
ing  very  violent  and  ( imtiMiinus.  Anotlicr  ,'yiM|>t(ini.  nlii  n  |irr,-(  nt. 
Ih  an  intense  tickling  irritatidii  <il'  the  snii  palalc,  iMdium^'  an  irre- 
fii-tihle  desire  tti  scralch  it  uilh  the  ton;,Mie,  r\iii  wli.n  ihc  |iaticni 
knows  from  c\|ierien<'e  that  the  very  friction  of  the  tMn;^iic  on  the 
t^uft  palate  will  inci.a-e  the  rapidity  >  f  the  sneezni;:. 

'J'lie  hydrostatic  eondilion  of  tlic  iiirhinated>  i-  partiiMilai  ly  mani- 
fest (hiring  an  atlari\  of  hay  I'eNcr,  the  par^-is  h,i\iiiL:  deprived  tln' 
tissues  of  their  normal  power  of  resistance.  \a\  the  |iali(iit  lie  on 
one  side,  in  a  very  few  moment>  the  ( nrre^pondin;:  iio.-tril  will  lie 
coiiiplclely  stenosed.  Let  him  turn  to  the  othei'.  and  the  condition 
will  he  at  onct!  reversed.  Let  him  lie  on  his  liack.  and  I  lie  posterior 
onds  of  the  two  inferior  tiirhiiiateds  will  liecoine  ^o  -uolleu  iLat  iliey 
will  iili  hotli  p(jsterior  choana',  and  hreathiiiL;  thioiieh  tlie  no.-c  will 
he  an  impossihility. 

Many  eases  of  hay  fever,  after  the  lirst  few  year.-,  al-o  taki'  on 
the  element  of  asthma,  to  increase  the  sidlerer's  mi.-eiy.  This  comes 
on  two  or  three  weeks  after  the  (■ommeiiceiiicnt  of  the  symploms;  and 
iji  some  cases  will  last  for  weeks  after  the  hay  fever  proper  has 
Ml  lis  i  (led. 

It  is  a  question  whether  the  a.-lhma  owes  its  origin  to  hay  fever, 
or  whether  they  are  not  hoth  the  products  of  the  one  cause,  pro- 
ducing vasomotor  rhinitis  in  the  upjicr  ri'^ioii  and  vasonintur  hnm- 
C'hitis  in  the  lower. 

One  remarkahle  peculiarity  of  hay  fever  is  its  exact  periodicity. 
Quite  frecpiently  it  will  come  on  year  after  year  almost  to  the  very  day, 
usually  ahout  the  '^Oth  of  August,  and  last  for  four  or  six  weeks,  or 
nntil  the  advtnt  of  cold  weather,  and  then  di>appear  aliiio.-l  a>  sml- 
denly  as  it  came. 

K.xamination  of  the  nasal  passages  during  an  attack  reveals  the 
turljinated  bodies  swollen  and  water-soaked  and  of  a  grav  or  pur- 
plish hue.  The  mucous  memhrane  is  painful  and  sensitive,  while 
the  necessity,  which  so  often  exists,  of  sleeping  with  the  mouth  ojien 
renders  the  throat  dry  and  i)arched. 

Througliont  the  Ignited  States  and  Canada  the  usual  period  of 
attack  is  during  the  latter  half  of  .\ugust;    hut   with   some  people, 


r: 


M 


fii 


»!»*; 


!i.s 


iii>i;asi.s  ui    I  mi;   n  asm,   r.\s>Atir> 


i 


^>' 


\\\o\\ixh  tilt  y  arc  {greatly  in  tlic  iniiioiily,  tlu'  attack  (•(uncs  oii  in  June- 
licnriiiLT  IIk-  iiimic  nl'  "rdsc-cditK"  t'rnm  tlif  I'licl  of  r 


uses  iiKKiininir  al 


lliat  tiiiic 


111    nllicr   iiisliiiiccs,    tiKMiL'li    llicsc  ii 


(•nines  (111  sciiii  aiiniiiillv 


I.  likewise  I'iire.  Ilie  nlliick 
li.-ive  (Hie  liidv  pill  lent  wIid  Iui'  years  !i:i(l  ii 
liiilit  attack  in  Miircli,  to  lie  rollowed  iiy  a  severe  one  in  Ahl'IisI.  'The 
latter  still  coiiliiuies,   t'ollowed  or  accoiiiiiiiiiieil  liv  a-llini.i,  wliilc  the 


rorincr  lias  diiriiiLT  receiil   years  d 


:sa|i|ieared 


Willi  regard  In  f;coL:ra|ihi(al  area,  il  is  I'diiiid  on  lliis  conliiicnt 
oxeraliiiosl  all  parts  (d' the  I'nilcd  Slates  and  ('aiiada.  'I'lierc  are  cer- 
tain rei^ioiis,  liowcver.  said  to  lie  excnipl,  siicli  as  the  While  Moiinl- 
aiiis,  the  Adirondaeks,  Maniloidin  Island,  jiarls  (d'  Miiskoka,  lli(> 
vicinity  (d'  (j)iielicc,  etc.  I'liil  il  is  said,  also,  thai,  as  iirhan  life  cn- 
lends  into  tlii'sc  regions,  their  loinier  iiiiinnnily  may  madiially  pass 
away. 

Diagnosis.  J'tM-haps  aciile  rliiniiis  is  llie  niily  disease  thai  it  is 
likely  to  he  niistaken  for.  in  this,  howoer,  the  chances  of  error 
are  slii^ht.  In  iiciitc  rhinitis  the  niiicoiis  meinhraiic  is  hriglit  and  rod, 
with  no  great  ainoiinl  of  swelling,  in  hay  fever  the  color  is  a  grayish 
or  purplish  red,  and  the  swt  lling  a  leading  feature.  The  discharge  in 
aeiit(>  rhinitis  is  iiiuco  pus  (d'  a  yellowish  color;  in  hay  fever  it  is 
liltl(>  hut   ('(dorless  seriini. 

Prognosis.  Hay  fever  rarely,  if  ever,  produces  a  fatal  result. 
Still,  while  it  lasts  it  causes  iiuicli  intense  sulTcring.  In  some  cases 
(luring  the  process  of  years  the  attacks  of  themselves  hecoine  gradually 
ligliUM"  and  iinally  disappear;  hut  in  the  majority,  if  uurelieve'l  hy 
ireatniiMit,  llicy  culminate  in  asthma  .d  a  severe  and  ('(nitinued  form. 
'I'lie  disease  is,  however,  more  or  less  amenahle  to  treatment,  and  a 
large  jiercentage  of  cases  have  Ikhmi   reported  cured. 

Preventive  Measures.  -.\s  a  preventive  ineasurt\  nothing  occu- 
pies .so  |)roniiiiciit  a  position  as  the  removal  fr(Uii  home-surroiindiiigs 
to  a  locality  where  hay  fever  is  said  not  to  exist.  Of  such  regions 
those  already  named  hear  a  high  repulalimi.  particularly  tlio  While 
.M(nintains.  l>etlileliem  seems  to  he  a  favored  spot  in  these  nuniut- 
aiiis.  The  cle\;iti(Hi  is  less  than  *.'(l(t(>  feel,  hut  large  niiinhers  (d" 
people  annually  spend  the  wlude  of  the  hay-fever  season  there,  and 
claim,  during  their  sojourn,  almost  complete  immunity. 

The  Muskoka  islands  and  lakes  hav(>  also  during  recent  yoar.'?  re- 
ceived a  good  deal  of  attention  as  a  !iay-f(n-(>r  resort.  The  elevation 
of  1000  fopf  above  the  sea.  the  purity  of  the  waters,  the  rooky  and 


. 


II. \v    i'i;vi;if,  ou  \  ASdMoTou  itiiiNiris. 


;»:* 


) 


siiiid}'  liiiliii'c  (if  llic  soil,  lli(>  iiliiiiulaiicc  nf  Wdiidhind,  iitid  liic  l(!Utii~ 
iii^  varii'l}'  III'  llu'  iMiniiiH'i'.'dili'  i>liiiids  liavr  all  liclpcd  to  iiiakc  it  an 
ideal  r(';;ioii   I'nr  llic  iiicvciil  inn,  ;is  udl  as  t  irai  inr'il ,  dl'  this  di.-i'aM'. 

Till'  ti|p|irr  \\alri'.->  111'  llir  Sa;4iitiia_\ .  iIhmil'Ii  Iduci'  in  clrNalinn, 
is  also  ;;aiiiiiiu  iii  rrpiilal  mii,  |iail  iiidai  ly  ai'mn;;  .-iilVrrns  dirrrlly 
Id  t  III'  Miiil  li  i.r  I  lii>  ii  una  111  II'  ir;;iiiii ;  as  aUn  i~  (lcurL'i;i  ii  liav,  Willi  ils 
jiiu'c,  (lr\    al  iii(i  |i|ii-ii',  ami   I  lhiii,-aiiil>  nf  rnck\    i-|;iiiil,. 

'I'lir  iiiii.-l  iinpnrhiiit  I'mcI  to  lie  ciuiMilriTil,  in  iiiinii  rl  kui  willi 
lliis  \ir\\  III'  |ii  i'\  I  III  iiiii.  IS  llir  ad\  isaliilil  y  nl'  iiihn  in;.';  I"  iIh'  iIhl^i'Ii 
s|iiil  lii'l'dTc  Ihc  rdimiu'iu'riiiriil  id'  llic  animal  allaik.  'I'lir  oiiji'cl  is 
1(1  ^rl  llic  ciilii-c  licndil  111"  the  rliiiialic  rlian,L:c;  In  |iri'\cnl  the  dis- 
ease I'liini  dc\clii|iiMji;,  muI  to  hi'cak  il  ii)!  aflcr  it  has  made  its  appear- 
ance. Annlller  pnilll  wllicll  cannnl  lir  Inn  st  l'nM;dy  em  [lliasi/.i'd :  if 
llic  palicnl  Udcs  hy  railmad  to  tlic  ravdicd  rcsni'l,  livfurc  tin-  time  nl" 
llie  annual  attack,  even  if  that  pciind  i.-  nidy  a  Few  day-^,  tlu'  syiiiplnins 
will  not,  dc\el(ij)  dnrin;;'  llic  jonriiey;  hut  it'  the  lii|i  is  made  (ij'lar 
the  hay-fever  symptoms  have  commeneed,  they  will  he  nialerially 
agf^ravalcd  hy  the  time  he  reaches  his  destination. 

'The  rcsnits  arising  from  this  inclhdd  of  prcvcnliiin  ditl'cr  ma- 
terially. In  some  cases  the  occurrence  of  the  disease  for  I  he  season 
is  lirokcn  entirely;  in  dthers  the  severity  is  weakened  and  tlu!  period 
of  the  attack  shnrlcncd;  while  in  others  lilfh;  or  no  salutary  etreet, 
is  produced.  They  may  i^o  the  round  of  all  the  resorts  lliey  can  hear 
(if,  and  yet  tlu!  liay  fever  will  e.xhihil  itself  with  its  (dd-time  foreo 
and  duration. 

Treatment. — 'I'liis  will  frciiuenlly  require  to  Ik;  of  a  threefold 
eharaeler.  1.  ( 'onslit utioiial  Ireatmeid,  for  tin;  correction  of  the  ikmi- 
rotie  liahil.  ^1.  Treatment  of  the  diseased  condition  of  the  nasal  pas- 
sages.    ;{.  'I'reatnient  of  the  spasmodic  attack. 

1.  Coiistitulional  treatment.  In  this,  rcfrulatinii  of  the  ali- 
irienlary  eamd  and  the  urinary  system  may  he  of  prime  iniportanc(!, 
and  should  he  followed  hy  Ihc  administration  of  nerve  and  syslenne 
Ionics,  such  as  iron,  (pnnino,  stryehnino,  arsonie,  and  |ihosphide  of 
zinc,  ('old  hathing  |tractiee(l  daily  is  an  excellent  adjuvant,  as  is 
also  sysloniatized  exorcise. 

liishop,  basing  his  eoiicliisions  upon  liis  own  theory  of  the  pres- 
ence of  uric  acid  in  tlu;  Mood  as  tin;  real  eanse  of  the  disen.so,  ad- 
ministers systctnie  treatment  liiider  the  title  of  ))reventive  treatment. 
In  the  first  place,  he  reduces  as  raueh  as  possible  the  supply  of  foods 
that  increase  the  formation  of  uric  acid,  such  as  meats,  sugar,  beer. 


,    Jc 


'  if 


100 


|)|si;.\m:s  or  tiik  nasai.  I'AssAtJKs. 


wine,  etc.:  nJid  limits  the  did  larirdy  to  rriiits,  vogclablop,  milk.  I'iits. 
ol(\;  1111(1  ill  tho  siuiu'  tiitu'  iKlmiiiislcrs  salicylatci'  for  several  weeks 
]iri(ir  io  the  onset  of  the  dij-ease.  in  order  to  diminish  the  iirie  aeid 
as  it    forms. 

Tlie  moment.  ho\\e\ci-.  ihal  ^\ni|tlonis  of  hay  I'ever  show  Iheni- 
selvrs,  he  drops  the  salicxlalis  and  r(>\erls  lo  acid  treatment,  .\fter 
numenms  evperiments.  he  |iitfers  llorsl'ord's  aeid  phosphates,  which 
he  i;i\es  in  l-uiamnie  dosis  two  im'  three  times  a  day.  lie  claims 
that  this  prexeiits  lhi>  solntion  of  uric  aeid  in  tln^  hlood.  and  at  (Mice 
checks  the  di><'ase.  while,  on  the  other  hand,  if  alkaline  treatment 
wei'c  re>ort(Hl  to  at  this  time  it  wonld  produce  iiricaciihemia  ami  pre- 
cipitate an  attack  of  the  lr(ndde  he  is  trying  lo  prevent. 

".*.  Treat nuMit  of  the  discasi'd  condition  of  the  nasal  passages,  in 
many  cases  the  hypera'sthetie  eondition  (d'  the  mncosa  depends  upon 
intranasal  lesions  of  one  torm  i>r  another.  It  is  self-evident  that  this 
discasi'd  (dmlilion  slnndd  he  removed  and  the  passages  rendci'cd  nor- 
mal if  possiidc.  neilcctions  o\'  the  septum,  hypertrophic  rhinitis, 
nasal  pidypi.  ])rcssnr(>  of  the  niiddl(>  fnrhinated  npon  the  se|)lnm  may 
any  of  tlnnn  re(piire  o]ieralive  interference:  and  the  trealinent  should 
he  dire(t(>d  toward  the  riMiioval  of  these  ediiditiinis  when  present,  ac- 
('(M'ding  to  tlie  methods  already  indicated  in  prcviims  chaplers. 

.\s  regards  the  period  l)est  suited  \i\  operatimi.  it  wonld,  without 
donht,  he  hetter  to  remove  all  ohslruetive  lesions  pri(M'  \o  the  annual 
onsi>t  of  llu^  disease.  .\s  a  ruK'.  however,  the  patient  docs  not  prcsi  ut 
liimsidf  for  trc.-itmcnl  until  the  se\(M'it_\  (d'  the  exaccrhations  impid 
him  \o  s(M'k  r(di(d'.  ^^  hen  he  (hies  cimie.  his  case  should  he  i>\amined 
into  tlKM'iMighly,  with  lhi>  aid  id"  the  neee-^sary  rliim^scopic  instrii- 
iiienls.  This  can  always  he  accomplished,  even  in  the  most  sensitive 
eases,  after  ajiplying  a  ■I-p(>r-eenl.  siduti(ni  of  cocaine.  The  essentia! 
th'Mn-y  is,  {\y<{.  to  remh-r  ea(di  nasal  passage  fre(>  enough  to  allow  of 
normal  re>pirati(ni  through  it.  and.  second,  to  nunove  any  pressure 
upon  the  septum  arising  fioni  turhinal  hypiM'trophy.  .\t  the  same 
time  it  is  always  well  to  he  guarded  against  too  extensive  operative 
interference,  and,  except  in  extreme  eases,  it  would  he  heller  not  to 
o))(>rale  during  the  actual  presence  of  this  periodic  disease. 

Sajoiis  and  ^racKenzie  Ixdieve  that  there  are  sensitive  areas,  in- 
dependent of  hy])ertrophy.  and  that  slight  galvanoeautery  operations 
upon  thorn  will  destroy  llio  terminal  filaments  of  tho  nerves  for  tho 
timo  being  and  thus  cheek  the  exaeerhations. 

'A.  'I'roatmont  of  the  spasmodic  attack.     No  troatnieiit  while  the 


! 


I, 


\ 


': 


HAY    I'KVKIt,    OK    VASOMOTOR    lllllMrif-.  10 1 

oxnccrbiitioii  is  acliuilly  nii  will  ^ivc  siuii  j mmpt  relief  as  i\  spray  of 
a  sdliilioii  of  I'ocjiine.  At  the  same  time  im  driiir  is  more  (latif^erous 
to  liie  palieitt,  if  lie  Iteeomes  aililiileil  |o  its  iiidiserimiiiate  use. 
\Vherever  tliere  is  vascular  tiir^esceiue  of  the  iKt>al  iiiiicosa,  from  any 
cause,  the  appli<'at  ion  of  w  solution  of  cdiaine  will  ai  once  remove 
it;  ami  in  hay  fever  the  ailemlant  symptiuu>  arc.  for  the  tiuu",  re- 
lieved likewise.  In  nmst  cases  the  followinj:  pre-^cri|ili(Ui  will  he  ijuite 
stroiiji:  on()n;ih:   - 

1.      U   (''xniiii'   li\  (Imclildr !M 

.Anuiioii.  cliliniil l.'l 

A.iiiu  :i(t| 

M.  Si^',:  S|ir;iy  imiIi  iii'^llil  willi  :i  >iiki1I  .|ii;oilil\  .\\\i\  iilln.v 
i)  111  lie  rcliiiiii'il.  Any  <,'oiiil  iidiiiii/cr  im-;  V\\i^.  -•"•, 
l!(i,  iiiid  L'7)   wimld  iuiswcr  I'nr  ^juiiy  I  iciil  mint. 

OiH'  dinicul'.y,  apail  from  the  ilani;cr  of  actpiiriuLj  the  cocuine 
Iiahit.  which  can  oidy  he  slii;ht  in  the  use  nf  <o  weak  a  solution,  is 
Ihe  fact  that  its  action  is  only  temporary,  and,  after  Iiein;:  used  n 
nnmher  id'  limes  in  succession,  the  reaction  from  the  condition  of 
the  vessels  prodiiccil  liy  it  liecomc>  rapid  and  iioticcaiilc.  That  is,  the 
tisstics  swell  up  aiiaiii  even  more  ipiickly  than  they  did  hcfoi'c  ils  w^v. 
Here,  a,L;ain,  to  prohmi;  the  ellicacy  of  the  cocjiinc.  i,rood  results  can 
he  olitaincd  from  a  'v*-per-cent.  solution  of  menthol  in  alholcne. 
thrown  up  the  nostrils  hy  a  second  atiuni/cr,  a-  .-ooti  as  the  cocaine 
has  heen  ahsorlicd. 

There  is  another  method  of  IrentmenI  I  have  found  very  salis- 
faclory,  in  which  cocaine  has  not  heen  use(|  at  all,  except  for  the 
purposes  of  examination.  'I'his  is  hy  usimr  a  much  stroii^rer  solution 
(d"  menthol  in  adiolene  as  sjiiay  to  the  Ihroat  only — inhalin;:f  it 
forcihly  diiriui;'  a  full  ins]»iration,  and  then  elosimr  the  mouth  and 
lireatliinir  out  fhrouuh  Ihe  nose.  This  is  repeated  over  and  over  aLrain 
until  relief  is  ohtained.  'IMio  stremrfli  id'  Ihe  sidution  mi^ht  he  :5, 
■1,  or  "t  |)er  cent,  as  the  ease  miii'lit  rcipiire,  repeated,  irrespective  of 
time,  ni^ht  or  day,  upon  tlie  approach  of  each  threatened  o.xaeer- 
hation. 

Tliere  are  a  niiinher  of  mentliol-inlialers  in  Ihe  market,  hut 
usually  the  n.«o  nf  tlie  spray  is  nttonded  hy  hetter  results. 

Bishop  advocates  the  n.'^e  of  a  1-per-cent.  solution  of  eamphor- 

1.     rt  Cocniiic  livdroclilor pr.  v. 

Anunoii.  clilorid pr.  ij. 

Aqua    Sj. 

M. 


imw 


■■»-i 


102  DISKASKS    OK    THE    NASAL    I'ASSACJKS. 

menthol  in  lavoliii  as  a  sjumv  to  thu  iU)so  in  tliis  disease,  gradually 
increasing  the  strength  to  ;5  ])er  cent,  it'  retjuired.  lie  claims  it  to  be 
blander  and  more  sootiiing  tiian  menthol  ahjiie.  1  have  used  it  on 
many  oeiasions,  but  still  jirel'er  the  menthol  ami  ihyniol-nienthol 
prejiarations.     Of  the  latter  the  following  is  a  good  fornuila: — 

1.  U  'lliyiiiol    15 

Mclltliol     15 

All.oU'lU!    30| 

This  should  be  used  as  a  spray  {o  the  throat  and  dinunished  to 
one-half  strength  when  iist'd  to  the  nose. 

Lennox  Urowne  has  moie  failh  in  ilie  local  a|i|ilieation  of  men- 
thol than  of  any  other  iliiiu'  in  the  relief  of  this  disease. 

K.  li.  Sluirly  lias  found  .-nulT  of  datnrine  in  >tarch  a  very  etli- 
cie.'U  remedy;  while  Fletcher  Ingals.  after  eautei  ization.  adnnnisters 
tonics,  together  with  the  loral  a|i|ilieation  of  eoeaine,  to  relieve  the 
exacerbations. 

In  severe  cases,  when,  from  liusiness  engagements  or  other  cir- 
cumstances, it  is  im]iossible  to  use  spray-treatment  of  any  kind  to 
relieve  the  exacerbations,  minute  crystals  of  menthol  dissolved  in  the 
mouth  will  elVieicntly  keep  the  sym]itoms  under  control. 

As  direct  sedatives  to  the  nuifuns  mend)rane  administered  in- 
ternally ]ierha]is  none  are  better  than  a  eond)inatioii  of  atmpia  and 
morphia  in  minute  doses.  They  have  a  ([uieting  elTect  upon  the  nerv- 
ous -ystcin.  as  well  as  an  astringent  etfect  ujion  the  mucou>  membranes. 
The  fcdidwing  is  a  good  formula: — 

2.  H   Atrojiiii  siilph (ii:{ 

M(>r|)liia  sulpli ,05 

M.     Miikc  into  100  taliK-ts. 

Sig. :    One  to  be  taken  every  two,  three,  four,  or  six  hours  ag 
required. 

Still,  as  with  all  narcotic  sedatives,  cocaine  included,  considering 
the  danger  that  is  always  present  of  forming  a  habit,  the  less  of 
these   medicines   tiiat  are   given    to   the   jiatient.   the   better.      When 

1.  B  Til yniol    pr.  ij. 

Menthol     pr.  xxij. 

Alholene    5j. 

M. 

2.  It  Atropia  stilpli gr.  %',. 

^I<iri)h.  sulpli gr.  x. 

M.     Make  into  100  tablets. 


HAY    I'EVKIi,    OK    A'ASOMOTDH    HIUMI'IS. 


lo:? 


ahsoliitciv   lU'ri'SMiry   tlu'   dniLT   sIkiuM    liu    p  re  pared   in   ilif   doilor's 
otlice,  and  not  in  tin'  way  ol!  ])roscri[»tion. 

Solis-Cnhcii  and  Waiiiifr  speak  lii;:lily  of  suprarenal-caiisule  ex- 
traet  in  the  treatnunl  dt'  liiis  di.-ease.  Sulis-Colien  administers  the  ex- 
traet  in  ."i-granime  (h)ses  live  times  a  day.  insuriiii,'^  tliereliy  a  "sneeze- 
less,  eiiryzaless"  niiilit.  Warner  I'avors  its  local  applieatinn  in  Iho 
lurbinal  tissnes.  with  nr  \\itli(Uil  eoeaine.  nl)taininir  excellent   results. 


I 


5 


Xasai.  HvDiioitKiKi: a. 

'J'liis  is  an  atl'eetion  somewhat  resendilin^ij  hay  i'ever.  particularly 
in  the  abundance  of  the  serous  discliarge.  It  i.s  very  rare  and  oceurrf 
at  irreguhir  intervals,  the  name  indicates  the  nature  and  symptoms 
of  the  disease.  The  discharjics,  however,  are  more  id'  a  passive  char- 
acter than  in  hay  fever,  and  unaccompanied  hy  the  severe  sneezing 
and  palate-irritation  which  attend  that  disease.  It  seems  to  arise  froni 
idiosyncrasy  of  constitution.  Sometimes  it  is  a  forerunner  of  nasal 
polypi.  How  far  it  may  stand  in  a  causative  relation  to  it  at  i)resent 
it  is  impossible  to  say.  Treatment  similar  to  that  id'  hay  fever  is 
called  for;  electrolysis  under  cocaine  anaesthesia  may  i»e  u.seful,  and 
operative  treatment  for  removal  of  ohstrnctions  may  sometimes  be 
required. 

A  case  of  "vasomotor  rhinitis""  reported  by  Howard  Straight, 
although  accompanied  by  severe  sneezing,  1  think  should  really  come 
nnder  this  head.  The  attacks  were  sin\ilar  to  those  of  hay  fever 
only  for  the  facts  that  they  come  on  move  freiiuently  durinir  wet 
weather  than  dry.  and.  lasting  a  day  or  two.  occurred  about  every 
two  weeks  all  the  year  round.  .V  nundier  of  liandkerchiel's  wo\dd  be 
saturate(l  with  each  attack,  and  all  (H'dinary  treatment  failed  to  give 
ndief.  Finally  the  doctor,  linding  the  entire  nasal  ]iassage,  tur- 
binateds  included,  in  a  normal  condition  when  the  attack  was  olf, 
singed  the  inferior  turliinatcds  lightly  with  the  llat  galvanocaulery 
electrode.  The  re>ult  was  a  great  improvement  of  the  I'oniliiion,  with 
almost  com])lete  >uli>idcnce  of  the  attacks. 

St.  Clair  'i'hom>oii  has  very  recent Iv  di-awn  attention  (n  jht^  pos- 
sibility of  mi-taking  escape  of  cerein'o-spinal  tliiid  for  nasal  hydror- 
rlnea.  the  s\mptoins  being  somewhat  alike.  A  number  of  cases  are 
recorded  in  which,  in  otherwise  pei'lVctly  healthy  sultjects.  cerebro- 
spinal fluid  W(ndil  escape  almost  continuously  from  the  one  nostril,  the 
intermissions  being  rare.  ]n  trui'  nasal  hydidrrlnea  the  discharge*  is 
more  irrc<ridar  and  at  the  same  time  bilateral. 


m 


■  f 


,;  I  ■ 


■i  ' 


'  ii  n 


CIIAl'TKU  XV 


ANOSMIA;  PAROS.MIA;  FUIIUXCULOSIS. 


Anosmia. 


hi 


I    -!  ft 


I  " 


Tins  (li?easo,  iiidiciitiiiir  li»ss  oL'  tlio  8L'iise  of  Pimll,  may  owe  its 
origin  to  either  eeiitral  or  |teri}ilieral  Ic.-^ioiis  or  to  mere  I'unelional 
distiirhaiiec  of  the  nerve-eeiitres.  Wlien  of  central  origin  it  may  arise 
from  the  pressure  of  a  tnmor  on  the  douljle  nerve-centre,  or  upon  the 
Ui'rves  tliemselvi's.  as  in  liodcr's  case,  in  whicli  tlie  pressure  arose  from 
scirrhus  of  the  j)ituitary  hody.  Appei't's  case  also  arose  from  press- 
ure U|)on  the  olfactory  nerves  liy  abscess  of  the  pituitary.  Bonet's 
case  was  caused  liy  pus-formation  within  the  olfactory  bulbs.  Jt  may 
arise  also  from  atrophy  of  the  l)ull)  or  trunk  of  tlie  nerve  as  a  func- 
tional result  of  insanity  and  as  the  result  of  U'sinn  caused  liy  fracture 
of  tlu^  bono  of  tlie  Inisc  of  tlie  skull. 

r)y  far  the  hirger  number  of  cases  arise  from  peripheral  com- 
pression or  lesion,  or  from  causes  that  will  prevent  the  contact  of 
odoriferous  particles  witli  tlie  olfactory  area  of  the  nose.  The  causa- 
tive eifect  of  lesion  of  the  terminal  ncrve-fllaments  is  well  illustrated 
in  cases  of  atro])hic  rhinitis  and  malignant  disease.  Here  the  nerve- 
endings  are  destroyed,  in  the  one  case  by  atrophy,  in  the  other  by  the 
substitution  of  neoplasm.  In  all  cases  of  anosmia  the  sense  of  taste  is 
likely  to  be  impaired.  Excessive  tobacco-smoking  will  sometimes  im- 
pair the  sense  of  smell.  The  pressure  of  nasal  polypi  not  infreipiently 
will  destroy  the  sense  also. 

"When  the  anosmia  is  the  result  of  atrophic  rhinitis,  a  thorough 
and  sy-stematic  treatment  of  the  latter  is  not  infrequently  followed  in 
the  end  by  restoration  of  the  olfactory  sense.  Joal  records  two  cases 
as  cured  by  douches  of  carbonic  acid.  ITe  applied  it  through  a  caout- 
chouc tube,  the  effect  being  first,  irritant  and  then  resolvent. 

"When  the  cause  is  central,  there  is  little  hope  of  cure.  Still,  the 
galvanic  current  may  be  useful  and  also  courses  of  treatment  by 
nerve-tonics  such  as  strychnine,  arsenic,  iron,  and  phosphorus. 

In  cases  associated  with  liysteria  and  insanity  the  affection  is  of 
(104) 


I 

i 


I'AUOSMIA.       riKUXCULOSIS. 


1U5 


minor  moment,  and,  as  a  neurosis,  may  disappear  with  tlie  restoration 
of  the  mind  to  a  normal  condition. 

r.VKOSMIA. 

Tliis  disease,  althonirli  very  rare,  may  manife.  I.  itself  in  various 
ways.  One  of  ihe  most  eommon  is  that  of  hypera^sthesia  of  the  olfac- 
tory nerve,  hy  which  the  palieiit  ]iei((ives  natural  ndors  with  exaii- 
gerated  inteiisity.  This  oeeiii's  chiclly  in  hysteric. il  >iihjeets.  Aii- 
othei'  Wiiy  is  liy  perversion  of  the  natural  function.  The  olfactory 
impi'is.-ions  iii  iMses  of  tiiis  kind  arc  usually  of  an  unpleasant  char- 
acter. The  odors  complained  of  ai'c  disaiirecnhlc.  .-ucli  as  carrion, 
kerosene,  fi'reasy  raid's,  etc.  It  is  >aiil  that  this  perverted  olt'actory 
function  is  )iot  infre(|uently  fiiuud  .■iuioml;'  epileptics  and  the  insane. 

Treatment. — This  .^IkiuM  he  dii  -iniilar  lines  to  those  recpiired 
in  the  treatment  of  anosmia.  Still,  as  its  oi'igin  is  move  likely  to  he 
central,  the  jiroLinosis  is  not  so  favorahle. 


Is 


l'"ri;r\rri.(isis. 

Small  hoils  within,  the  anteiim'  nares  arc  nni  hy  any  means  in- 
freipient.  'i'licy  ju'oduce  sor<'ness,  redness,  and  swellim:'  of  the  !nd 
of  the  nose.  'J'hcy  occur  most  fretpiently  at  ihe  outer  mar^iin  of  the 
vestihnle  or  the  inner  side  of  the  ala,  havin.ir  their  (n'igin  in  disea.-ed 
hair-follicles.  The  nmst  notahle  sym])tom  is  general  soreness  of  the 
part,  with  sharp  jiain  produced  hy  Idowing  or  handling  the  nostril. 

Treatment. — Systemic  and  local  treatment,  hased  on  general 
principles,  is  recommended.  .\  local  application  of  a  '-iO-jjer-cent. 
solution  of  camphor-menthol  in  lavolin  is  recommended  hy  Hishop; 
also  a  12-por-ccnt.  solution  of  carholic  acid  in  glycerin.  When  pus 
is  found,  he  recommends  evacuation,  followed  hy  a])plieation  of 
yellow-oxide-of-mercury  ointment. 

I  have  found  a  simpler  treatnuMit  speedily  ethcacious.  When 
the  little  hoil,  or  furuncle,  is  fm'ming.  Iiefore  pus  can  have  developed 
at  all,  a  sharji  needle  should  ])0  pressed  deeply  into  its  centre.  This 
can  he  done  hy  the  patient  without  the  aid  of  the  surgeon.  Tlien, 
by  vigorously  blowing,  blood  is  freely  evacuated.  This  blowing 
should  ho  repeated  a  lunnber  of  times  in  (piick  succession.  If  blood 
does  Tiot  appear,  the  little  operation  should  he  repeated  until  it  does. 
The  evacuation  will  have  relieved  the  congestion,  and  healing  takes 
place  at  once  without  after-treatment. 


I  t 


CIIAITKIJ   XVl. 


. 


Kl'lSTAXlS, 


i 


'Tills  term  is  ii|)|)li('(l  to  iiU  cases  ol'  luisiil  liii'iiiorrhiijii!  wliatovcr 
the  origin  iiiny  lie.  It  is  ol'  rrt'cuu'iit  oc-ciirrrncc  in  childhood;  I)ut 
imich  rarer  in  ndiilt  life. 

Pathology. — The  hh'cdin.u  nsually  arises  from  erosion  or  rupture 
of  tlic  minute  blood-vessels,  and  in  the  majority  id'  cases  comes  from 
the  lower  ]iortion  of  the  cartilaginous  septum.  Cliiari  believes  the 
majority  of  cases,  particularly  in  adult  life,  are  tubercular,  lie  gives 
a  record  of  si.x,  in  all  of  which  the  niicroscope  proved  the  lul)ercular 
nature  (d'  the  disi'ase.  Hard  granulations  or  tumors  had  formed  on 
the  septum  and  from  these  the  bleeding  had  occuri'i'd.  In  malignant 
disease  luvmorrhage  may  be  severe,  from  any  part  of  tlu>  neo])lasm, 
and  the  same  is  true  of  fibroma,  only  that  in  the  latter  spontaneous 
haMuorrhage  is  more  rare,  owing  to  the  deii.-ity  of  tiie  fibrous  tissue. 
I'ndoubtedly  many  lasi's  occur  without  the  system  in  any  way  being 
involved. 

Etiology. — In  cbildren  the  most  fretpient  I'auses  are  falls  and 
blows  ujioii  the  nost'.  Ticking  the  nose  and  the  insei'tion  of  foreign 
))odies  also  give  rise  to  if.  In  deviaticm  of  the  septum  the  erosi(m 
of  the  prominent  point  of  tlu'  cartilage  by  particles  of  dust  may 
proiliicc  bleeding,  as  also  may  fi'acliii'cs  of  the  nose  m  the  base  of 
the  skidl. 

Sometimes  the  hjcuKU'rhage  may  lie  vicarious  in  plaee  n\'  su<- 
peniled  intMistruation.  W'licn  occurring  after  th<^  nieiinpaii-e.  it  may 
lie  considerc(l  an  elVort   to  !'clie\i'  the  di-teiided  biddd-vc.-.-els. 

At  other  times  il  may  aii-e  from  const  il  ut  i(Uial  cachexia,  .-iicli 
as  pei'iiicious  aiia'iiiia  or  pui'pnra  lia'inoi'i'hagica.  or  again  fiom  organic 
<lisease  id'  the  heart  or  kidneys,  as  a  iircmonifory  sign  id'  typhoid,  and, 
as  alreaily  said,  as  the  r(\-;ult  (d'  septal  fuberi'iilosis. 

Symptomatology. —  It  often  occurs  withoiif  premoidtory  -ymp- 
toms.  In  other  cases  prodromic  symptoms  of  vertigo,  headache, 
throbbing  of  the  temples,  etc..  ])recede  the  vnous  discharge.  Pro- 
fuse arterial  ideeding  rarely  occurs,  except  from  malignant  disease, 
(100) 


Kl'lSTAMS. 


\o: 


fihi'oinii,  nr  iriiiiiiiMliiiii.     As  m  riilr.  tlic  luriiuirrliiiiif  ncnirs  diilv  rroiii 


oil''  iidsinl 


Diagnosis. 


II    llli>    llli'l'c   >l|nlllil    lie    111)   (lillicllll  y 

h 


11    lllc    hli'C(M!|i| 


ncclllS     while     Ihr     |illllt'lll      1-     111     ;l     CollscKUIS     I'nIHill  Kill.         I'  l('(  |  llcllt  Iv. 

Iiiiw cvt'i'.  >li,L;lil  liu'iiinirliiiuc  \\in  ncciir  in  ilic  iii^iht.  If  llir  |i;iti('t'i 
is  ;i>l('('|i  ill  the  ,-ii|iiiii'  |i()silii)ii  iin  diM-liMrui'  iiiiiy  r.-cii|i('  Iroiii  ilic 
jinlcrinr  iiiiic.-.      I'd-trrior  rliiiiiis((i|iy  cscii   in   llicsc  ca-r^  slioiiM   H'- 

IllOVC    t  111'   lidlllll. 

Prognosis.^      In    inillnr   lilcnlill^-   lIlc    |l|nnni]<is   i.~  ;ilu;i_vs    |■;l^  .irillilc 

in  (li|iliili('ria  hihI  ihr  laltcr  .-la,L;rs  o\'  i\|i|ii)i(|  ii  is  iini  -o  lidpcl'iiK 
while  liaMiKirrlia^e  (iccui  riiiu'  in  iiiali.uiiaiil  ili>ease  ami  |iiir|iiiia  may 
he    (■n|i>i(|ere(|    ii~    II  |l  j'a  \Oialile    i  111  I  ical  idllS. 

Treatment.  If  the  altack  is  mild.  siniiiL:  i|iiielly  in  a  chair  with 
the  lu'.iii  tilteil  .-liuhlly  liarkwanl  will  nl'leii  arre,-l  the  hleediiiLi-.  If 
tlie  jialieiii  heiids  his  head  fnrward  tn  elean.-e  tlie  iin^lriN  id'  the 
eliilled  lilnnd.  lia'imirrhaLJe  will  eiimmellee  auaiii:  lint,  let  him  iilnw 
(lilt  the  ai  i'nMinlatinii>  and  at  miee  roiime  the  fdrimi  {i(i>itinii,  it 
will    lie    likely    tn   sdon    eeax'. 

I 'dill  Id  the  .■•|iine.  Iidt  a|i|ilieal  idii-  tn  ihe  eMeriial  iid.-e,  Imt- 
waler  ddiiehes  In  the  lid.-tlil,  |i|edn(.is  df  cdttdii  snaked  ill  i;lyeern- 
laiiiiin  iir  tincture  n\'  inm  ha.ve  all  lieeii  recninniended.  It  is  I'arc, 
liowt'Vcr.  that   activt'   treatiiieiit    will    he   necessary. 

When  hIeediiiL;-  threatens  tn  he  severe,  il  i-  Well  liy  meaii»  (if 
the  nasal  <|iecnliiiii  and  rellected  lii:ht  tn  search  fnr  the  lileediii,i:- 
Jinint  and  tn  |iack  the  >|ini  lirmly  with  cnlldii  |i|edL;'ets  ahme  or 
saturated  with  astriiiLi'enls  ali'cady  iiienliniied.  In  these  cases  kite- 
tailed  tiiin])()ns  answer  an  excellent  |iiir])nse.  Small  )iieces  i)\'  aseplie 
nlisnrbeiit  cntdni  are  tied  inn;ether  hy  a  striiia'  at  inti'i'vals  nf  one  inch 
and  a  half  frnin  each  nther.  'They  are  all  then,  after  cncaini/.in^  the 
imicniis  ineniiirane.  packed  mie  after  aiidtlier  intn  the  hleedint:  nnstril 
liy  means  nf  enllnn-hnliler  nr  small  curved  fiirceps.  until  liy  pressure 
the  Inemorrhaiie  ceases.  'I'lie  pliiu'  is  lelaineil  fnr  tweiity-fniir  nr 
fnrty-eiii-ht  hniirs.  .\fter  thai  the  wlmle  nr  part  nf  the  pieces  may  he 
withdrawn  hy  t:-entle  tractinii.  a  pnitidii  liciii^  retained  tn  the  third 
day  if  the  return  nf  ha'innrrhaii'e  appeared  tn  lie  pi'dliahlc. 

In  anlicipatinii  nf  the  latter.  In^als  siiLiui'^t-  the  u~e  nf  a  strip  nf 
'"odofnrni  izaiize  as  less  likely  tn  heenme  oll'eiisive  dnrinu'  a  prnlniiLred 
retention. 

Vnr  deep  packing  (ileasnn  also  iis(>k  a  lon^'  strip  nf  iraii/e.  snaked 
in  one  of  the  hydrocarbon  oils  and  packed,  fold  after  fold,  hack  as 


II 


■!■'.:« 


»»^WJ.-g<»^;«'<M918W<B 


108 


DISKASKS    OK     I'lll-;    NASA  I.    I'ASSAdKS. 


fiir  as  the  jKi-^tcriiir  clioaiia'.  AmUlu'r  iiK'tlmd.  which  lie  roiisich'is 
c(|iiiilly  t'tliciicii'iis.  ill  the  (lu'ckin^'  of  (li'cp  ha'iiiiiri'hii,ur.  is  to  sunk 
a  loosi'  pit'io  (il  ahsiirlit'iil  colioii  in  a  l.'j-vohiiiu'  solutinii  of  pcioxiilo 
ol'  livilniucii,  and  lo  ]>Yv>-i  it  ahmi;'  the  iiilViior  nu'atns  to  the  pos- 
terior iiaiis,  as  in  tlic  lirsl  iiicthutl.  llo  ehiiins  tliat  l)y  tliis  moans 
posterior  |iaekin,:i  can  Ik-  avoided. 

In  po<t-rhiiial  ha'iiiorrhai:e  from  inali^naiit  or  lihroid  diseases 
these  methods  may  all  fail:  then  rn-ljoeii's  eaiiiiiihi  (l''i,u'.  o'))  will  do 
exeelleitl  sei\  iee.  'I'he  olijeetioii  to  this  inst riiiiieiit  wlii'ii  first  intro- 
diR'od  was  on  aeeoiiiit  of  the  curve  in  the  tuhe.  That,  however,  has 
vanislied,  as  the  in-triinieiit  now  in  use  is  almost  straii:ht.  The  oh- 
jeet  aiiiu'(|  at  i.-  to  pliiLi'  the  postiTiiu'  miris  of  the  hleetlin^  side  lirst 
and  the  anterior  iiaris  afti'rward.  The  •.•a:Jiuila  is  tlireadcd  with  a 
stroiiiT  eon!  throiiirh  tlu'  eve  of  the  spriiii;'.     The  thumli-serew  is  next 


J'ij;.  .").").     I!t'ili)((i"s  cannula. 


adjusted  so  that  it  will  retain  the  spring  within  the  cannula.  'I'lien 
the  instrument  i-  passed  aloiij:  the  lloor  of  the  inferior  meatus  until 
the  end  projects  heyoiid  the  vidnm.  The  spring  is  now  touched  and 
the  cord  is  at  once  seen  witliin  the  mouth.  'I'o  tliis  eord  is  fastened  a 
jiledget  of  wool  large  enough  to  lit  tlu'  ])ostei'ior  naris.  Then  the 
cannula  is  withdrawn,  the  wool  pulled  through  the  nosti'il  iiiln  posi- 
tion, and  cut  loose.  In  drawing  tin-  cotton  through  the  naso-pharynx 
it  can  lie  guide(l  in  its  course  hy  the  ling'  r  of  the  left  hand  of  the 
operator. 

It  is  claimed  that  the  cotton  plug  should  he  large  enough  to  liU 
both  jiosierior  nares,  as  otherwise  the  ha'inorrhago  might  continue 
from  the  free  side.  This  looks  like  false  logic,  as  there  is  no  natural 
communication  hetween   the  two  j)assage8. 

In  a  ease  of  a  severe  liaMnorrhage  from  nasal  fibroma,  the  only 
occasion    in   which   T  have  ever  rccpiirod   to  nse   this   instrument,   I 


Ml 


I' 


Kl'lSTAXlS. 

I''"--''''  ""■  "'!''  >i'l''  «'i,!y.   r„!|nur.|    |,v 
iiii'iiiorrliii^rc. 

'AlKitlirr   |il;m   of   Ifcjlli 


109 

ii'i"i'''liiitr  (TssiilinM   ,,]■  the 


;;;.;;;:;':::;;;:;::;;::r,^:::j:';;:-:: 


■  4 1 


CIIAI'TKR  Wll. 
luiiNoi.iriiS;   i()i;i;i(..\  uodiks;   i'akasitks. 

TilllNOI.IIIIS. 

A  i!ii  iNni.iiii  i-  a  iiii>al  (alculii-.  It  is  rorincd  l)_v  tlic  u'i'ailiial 
(Ifjiosit  (if  till'  iniiicial  cdiistil  iiciils  nf  llic  iioriiial  iuimiI  socrclioiis 
U|)(iii  the  >iii-|'aii'  (if  sniiic  lorci::!!  Iiody,  li)cnti'il  witliin  tlio  nose  iiiid 
lu'tiii.ir  ;i>  a  nucleus. 

'I'lic  rarlir-i  rccdiil  tpf  (Uic  liciiiu'  I'l'inovrd  \\a>  n'|Mi|-t('tl  liv  (Jardi 
ill  1A(i".'.  It  \\a-  indcliiiiudy  dc-ciilii'd  a-  liciii^'  a-  lar,m'  as  a  lii'-coiu'. 
Dui'iiij.'  the  Iniir  cciiturii'-  li'iuii  ilicii  until  lunv  uuut  than  a  humlrud 
liavc  1u'cn  ilii'niiirlcd.  SiiU.  rliinolitlis  arc  of  rare  occurrcMcc  and 
tlu\v  nccni'  so  inri(M|Ucnlly  that  each  individual  i^ase  is  usuallv  coa- 
sidorod   Wdrlhy  dl'  a   ri'cni'd  hy  itself. 

In  the  mailer  id'  hi-tury,  ihey  I'nlldw  the  same  law  that  jxtiverns 
tile  I'dMuatinn  nf  calculi  in  the  hladder  and  olhcr  orirans  of  the  hody, 
and  in  most  instances  snnie  trace  of  iiucleiis  can  he  round.  It  usually 
tiikos  many  years  from  the  insertion  of  the  oriirinal  I'oreijxn  hody  in 
the  nasal  cavity  to  the  full  development  of  tlio  rhinolith,  as  seen 
when  the  patient   applie-  to  ihe  siiruciin   for  relief. 

Symptomatology.-  Someiimes  from  their  size  and  position  they 
'/wo  rise  to  great  deformity.  In  llendloy's  case  the  nose  was  swollen 
and  there  was  an  external  >inu>.  Iroiii  which  jius  exnded;  in  UovilTs 
case  facial  ]iaialysis  ami  destruction  of  the  hard  palate.  In  Ilill'.? 
case  the  rhinolith  wa-  veiy  larLie  and  had  caused  extensive  rhinitis 
caseosa.  In  .Mar.-ITs  case  there  was  marked  deviation  of  the  septal 
cartila.u'c  to  the  left,  heliind  which  the  calculus  lay  concealed.  One 
of  ihe  writer's  ca.-e-.  a  </\v\  (d'  1!'  years,  was  similarly  all'ected,  hut  in 
her  case  it  was  on  the  riirlit  side.  On  rcniovinir  a  portion  o\'  the 
hypertrophied  and  deviatetl  cartilage  the  stone  was  discovered  he- 
hind.  It  was  liroken  in  i'rairinents  and  removed.  The  nucleus  had 
lieen  a  cherry-stone  pushed  into  the  nose  when  the  patient  was  six 
years  of  age.  In  ihe  other  case  of  which  an  illustration  of  fragments 
of  exact  size  is  given  (Fig.  ."if))  the  stone  was  exceedingly  large.  It 
(110) 


\ 


iiiiiMH.n  ii>. 


1 1 


filled  llir  wlinlt'  III  ilic  iiili'iiiii'  lui'iitii^  iiml  iiail  li>  ln'  lii'ukt'ii  ii|i  liit'ort' 
it  foiiM  III'  rciiinvnl.  'I'lic  initlcii>  \\;i>  II  liiiitiiii,  US  .-littwii  in  tlu'  iipjifi* 
rif^lit  ciiil  III'  ilii'  lii:iii('. 

One     |)I'iillli||rlll      .-yill|itiilll     illtrllllin.L:'     nil     cm-.'-     nf     Inllif     -tlllnlillU' 

is  a  siininiis.  iiiiico-ituiiilfiil  ili-ili;ir::r  n|  |ir(iiliiiil\  iin|i|('n«iuil  ihIhi-. 
It  is  aliiiDst  cliariirtcrislic  nl'  tlir  ili^'ii-r  iiml  (jiiiir  ilill'i'iTiii  rniiii 
tiiat    |irniliiici|   liy  ntrojiliir  iliiiiili-. 

Diagnosis.  A-  ilir  ilr\r|ii|inii'iii  nf  ilnniilitli-  i-  a  -Inw  iiniccss. 
tlicv  I'jii'rly  iMiiiic  iiinlci'  iiliM'i'\aI  lull  iiiilil  ;iiiiill  lilr.  I'.y  lliis  liiiH', 
I'i'iiiii  llirir  ^izi'.  till'  >yiii|itiiin~  Kriniiii  -iM  IT.  In  iliilillimul  iiiiv  liaiil 
siilisiaiicr  I'liiiiiil  within  llir  nn-i'  i-  likrly  tn  ln'  a  I'nrcii^ii  luuly, 
witlinnt  ilic  calcafrniis  ilr|iii«it.  altlnMi^li  Imtli  (.'lark  ami  Jtabur  rcpDfl 
ca.scs  oi-i-urrinu'  in  rhiMiTn. 

In  (liiTci  r.Viiniinatinn  tli''  urilly  -riisniinn  lU'ndniril  liy  tlir  tmi'-li 
(if  tlu'  |ii'(i!ir  i>  inilii-at  i\i'  III'  raliiilu-.  Wlim  ciiivat  ur<'  ni  ilir  M'ptiiiii. 
as  ill   tlic  IW'i  ca:-!'--  rrlalcil.  Iiiilr~  tlir  -tiuir  rrniii  iiii-irvat  inn,  the  illi- 


i  i 


;  '1 


! 


YiiS.  .")(!.      liliiiiojilh  rciiiii\ cil   irmii  the  Ift't   iia-iij   |i:i--ii^'i'  ui'  a  laily,  ajri'd  -^. 
niiictcrn  M'ais  afli  r  (lie  in-crliiin  nf  tlii'  Iniltiiii  iiitn  the  iiii<|iil. 


podimoTit  may  rci|iiir('  to  lie  rcrmivi'il  licfnn'  the  (liai:iin-is  can  lie  niadi' 
sni'c. 

Prognosis.- -Til (•  I'ldar-vd  (■alciilns  can  never  lie  reimived  e\ce|it 
])y  o)H>rat ion.     Siiri:ical  relief  liy  one  means  or  dtlier  i-  always  ])os>il)|c. 

Treatment. — This  is  simply  the  removal  of  the  ihiiioliih  like  any 
other  forei,<.ni  lindy.  'i'his  can  rarely  he  acc(mi])li.-lied  without  thi> 
enisliiiiji'  or  hreakinu'-np  process.  l-'ortiinately  they  are  not  often 
dense  enonuh  to  resist  the  force  of  com|iressinn-l'orceps.  and  wlu'ii 
that  ilensity  (\n^^>  exist  small  lithofriies  may  he  \\<fi\  instead. 

Some  opci'aloi's  have  found  it  ni'ce--;iry  to  enlar,LM'  the  nasal  ori- 
fice by  incision.  Others  have  cut  thrniit^h  the  snfi  palate  or  perforated 
the  hard  palate  to  facilitate  removal.  iWit  these  cases  occurred  in 
earlier  years;  and,  \viili  the  improved  facilities  of  cocainizaiion.  ox- 
.imination.  and  puraical  treatment  of  the  pr(\scnt  time,  the  .surtreon 
should  not  reiinire  to  resort  to  any  elTorts  save  prr  rias  vahirahs. 

After  removal  of  the  rhimdith  there  nuiv  he  MHiie  ha-morrhaffe 


•  ,  I 


■  \l  i 


113 


DISKASKS    OF    THE    NASAL    I'ASSACKS. 


)^!C 


Hi  I' 


ii^ 


caused  by  contusion  of  the  soft  tissues,  but  liealing  is  always  rapid. 
Odor  entirely  disapjjcars  and  the  catarrh  almost  at  once  ceases. 

FORKIGX    ])0T)1ES. 

Foreign  bodies  are  ])ut  in  the  nose  l)y  children,  sometimes  by 
hysterical  fcinaK'S,  and  occasionally  by  insane  persons.  They  have 
been  known  also  to  enter  the  nose  dui'ing  sudden  insjjiration,  and  to 
have  got  there  by  accident  of  one  form  or  another.  In  tlie  act  of 
vomiting  masses  of  undigested  food  have  been  thrown  u[)  behind  the 
pafate  and  into  the  nasal  foss;e.  Bosworth  lelates  an  instance  in 
which  he  removed  a  deciduous  tooth  from  a  gentleman's  nose,  which 
had  loosened  and  been  swallowed  when  a  lad.  It  had  probably  been 
vomited  and  thrown  into  the  naris,  causing  purulent  rhinitis  for 
twenty-live  years  before  the  coctor  was  called  to  remove  it.  Lowndes 
tells  of  a  ring  l)eing  ini[)acte(l  in  the  jju^terior  Jiares  of  a  child  of 
IT)  months.  It  was  too  large  to  have  got  there  through  the  nostril. 
Cotton  tamjions  have  been  renu)ved  after  remaining  in  the  nose  for 
years.  Young  children  frequently  put  buttons,  peas,  pebbles,  etc., 
into  the  nose. 

Sometimes  if  they  give  little  trouble  nothing  is  said  about  them. 
If  discovered  within  a  year  or  two  they  may  be  found  unchanged. 
But,  as  is  mentioned  in  the  first  jart  of  this  chapter,  if  retained,  they, 
in  course  of  time,  become  the  nuclei  of  rhinoliths. 

Symptomatology. — Profuse  tero-mucous  discharge  accompanied 
by  sneezing  are  the  earliest  symptoms.  Tlicrc  may  also  be  pain,  par- 
ticularly if  the  object  is  rough,  ajigular,  or  large.  Subsequently  the 
discharge  from  ])ressure  nuiy  liecomc  muco-])urulent  and  of  oll'ensive 
odor.  Obstruction  is  also  a  prominent  symptom,  arising  partly  from 
the  pressure  of  the  foreign  body  and  partly  from  swelling  produced 
by  the  irritation.  Toleration,  however,  in  many  instances  soon  occurs, 
as  the  body  usually  lodges  in  the  inferior,  or  largest,  meatus — a  region 
less  liable  to  irritation  than  the  olfactory  areas  aljove.  The  seui-e  of 
smell  is  rarely  affected. 

Diagnosis. — This  can  only  be  jnadc  by  direct  inspection  wdien 
the  patient  is  either  ignorant  of  the  fact  or  unwilling  to  tell  what  he 
knows.  Cocaine  should  always  be  used  during  examination,  as  it  jjcr- 
forms  the  double  duty  of  shrinking  tlie  tissues  and  at  the  same  time 
relieving  their  sensibility.  AVith  the  use  of  a  ])robc  aided  by  re- 
flected light  and  nasal  si)eculum,  there  should  not  be  much  dilliculty 


fP- 


rOliKlGN    liODlKs.       I'AUASriES. 


113 


in  diagnosis.     In  young  children  a  gonoral  aiiii'stliolic  might  be  re- 
quired.    The  touch  of  the  prolie  should  distinguish  it  from  calculus, 
Mhile  thorough  o.xaniinalion  should  rcuiove  all  neojjlasms  by  exclusion. 
Treatment. — An  auivsthelic  will  he  re(|uire(l  dui'ing  renu)Yal  in 


iMtr. 


1)1  . — .>|I(HI|1. 


J 


most  cases  occurring  in  young  childrfU,  but  in  some  complete  aniws- 
thosia  may  not  be  necessary.  The  ajijilicalion  of  a  drop  or  two  of 
.solution  of  cocaine  to  the  mucous  memhrane  will  shrink  the  tissues 
and  facilitate  i'.\tra;lii)n. 


Fig.  58.- -I'osw drill's  ua^a'   fureeps. 

A  nasal  spoon  (Fig.  51)  in  ilie  majority  of  instances  will  readily 
remove  the  object,  ■  hough  sometimes  mouse-toothed  or  curved  nasal 
forcejis  may  bo  re^'.'ircil  (Figs.  oS  to  (iO).     When  these  fail  a  snare 


may  possibly  be  slipped  ovi'r  some  projecting  point,  and  render  the 
extraction  easier  than  by  any  otlu^r  method. 

r.vn  vsiTi:.'^. 

The  presence  of  extraneous  or  jiarasitic   life  within   the   nasal 
cavities  is  very  rare  in  temjierate  climate?,  so  rare  that  many  rhinolo- 


K 


114 


DISEASES    OF    THK    XASAL    PASSAOKS. 


I'll 


gists  linvc  iiovor  scon  a  riisc,  wliile  in  trnjiical  countries  it  is  compara- 
tively fro(iucnt.  In  Jndia  alone  Laliory  collated  91  cases,  2  of  which 
were  fatal.  Jn  ("hxinet's  case,  a  man,  after  slee])ing  in  an  open  field, 
was  seized  with  severe  pains  in  the  foreliead  and  with  swellino;  of  the 
face.  He  was  taken  to  a  hospital.  Worms  commenced  to  crawl  about 
his  nostrils  and  ears;  and  on  lancing  the  swollen  tissues  several 
platefiils  are  said  to  liave  been  taken  away  (l'»osworth).  The  i)atient 
recovered  Mith  tlie  loss  of  his  eyes. 

Fraenkel  says  that  in  teni])erat(!  climates  the  presence  of  ozainn 
is  favorable  to  the  gnnvlli  of  parasites,  ami  that  the  most  active  enti- 
ties in  producing  tiie  malady  are  the  Mitsca  romiloria,  the  Muf^ra 
carnaria,  and  the  gadfly. 

fjoldstcin,  in  tiie  Laryngnscope  lor  December,  1897,  graphicabv 


Fig.  GO.—  Hiirtniann's  foitciis. 


!:lr:: 


(       .'1 


introdnci's  a  new  insect  to  tlie  notice  of  his  professional  brethren. 
This  is  tiie  Cotupsoniijia  macceUaria,  or  Texas  screwwo:;u-fly.  Pro- 
fessor Williston.  of  Yale,  says  that  it  prevails  everywhere  from  Canada 
to  I'atagonia. 

Til  is  ]Hst  n>nally  confim^s  its  ravages  to  cattle,  b\it  sometimes  it 
invades  the  nasal  passages  of  human  beings.  Several  deaths  have 
been  recorded  from  its  effects.  In  all  the  known  instances,  bow- 
ever,  in  wliich  the  (>ggs  of  the  screwworm  have  l)een  dejiosited  in  tin; 
nose  or  ear  there  has  been  either  ]U'c-existing  oza^na  or  otorrhn^a. 
Tlie  lly  deposits  its  eggs  upon  decaying  anhual  or  vegetable  matter, 
and  upon  this  tlie  lly  feeds  voraciously. 

Symptomatology, — The  symptoms  in  all  cases  are  pretty  nearly 
alike.  These  are  excessive  irritation,  excruciating  pains,  formication, 
and  the  ajipcarance  of  the  maggots  craMling  within  the  nasal  cavities. 


PARASITES. 


115 


Tlicy  arc  very  tenacious  of  life,  and  wil!  stick  to  tlie  walls  of  the 
passages  with  great  tenacity.  Muco-i)uriilent  and  bloody  discliarges 
soon  follow,  accompanied  by  headache,  fever,  and  other  constitutional 
symptoms.  When  death  occurs  it  is  probably  due  to  the  supervention 
of  cerebral  meningitis,  possibly  aided  by  the  development  of  septi- 
ca'mia,  from  the  extensive  supi)urations  which  sometimes  occur. 

Treatment. — -'J'he  best  treat n'.eut  is  to  curette  and  pick  out  the 
larva".  The  scrttwworm  i.s  said  to  be  so  tenacious  of  life  that  it  will 
live  for  several  minutes  in  pure  carbolic  acid.  The  vapor  of  chloro- 
form, if  conconlrated,  will  kill  them;  but  care  would  be  required  lost 
in  zeal  to  destroy  the  parasite  the  patient  shoidd  be  sacrificed.  Ordi- 
nary washes  and  s])rays  are  useless.  Rigid  watchfulness,  with  oft- 
repeated  extractions  of  the  gnd)s,  aided  by  cocaine  and  retlected  light, 
would  appear  to  be  the  best  treatment. 

Scbappegrell  advises  the  use  of  warm  oil.  He  says  it  destroys 
the  larvse  by  occluding  their  respiratory  organs.  He  ])laces  the  i)a- 
tient  in  the  horizontal  position,  and  fills  the  nostril  with  the  lluid: 
olive-oil,  albolene,  glycolin,  etc.,  and  claims  to  eradicate  the  worm 
by  careful  and  painstaking  use  of  this  means. 


'Mr  'J 

i  1 


!(    .M 


it.     t 


m 

pi 

Ml! 


■J 


WW  11 


1 1        I     i'- 


('IIArTKJi  XVII I. 


NASAL  roLYI'I. 


TiiKSE  arc  tiiinur=  nf  ihe  7iii^e,  luescnting  several  marked  char- 
acteristics. Tlu'V  liavc  smooth  surfaces,  arc  lobiilatetl,  but  usually 
are  rcirujar  in  form,  each  hcini:  attached  by  its  own  Itmad  or  narrow 
])cdicle.  The  color  is  jirayish  hluc,  sometimes  slightly  jiink.  They 
are  tense  .id  elastic  to  the  touch,  and  arc  of  jelly-like  consistency. 


i.       ^ 


•:  t  ' 


i^ 


Fig.  01. — Xasal  polypi.     (After  15osworth.) 

They  rarely  appear  simultaneously  for  the  first  time  in  both  nasal 
fossa\  but  attack  one  nostril  first.  Sometimes,  through  a  long  course 
of  years,  the  other  one  is  never  invaded.  In  other  instances  the  de- 
velopment of  polypi  on  one  side  is  quickly  followed  by  their  forma- 
tion on  the  other  (Fig.  ('•>]). 

Pathology. — This  is  a  subject  in  which  there  exists,  particularly 
among  recent  writers,  a  considerable  difTerence  of  opinion. 

Biibroth  classes  nasal  polypi  with  the  adenomata;  Bosworth, 
(lUi) 


XAiiAL  roLYri. 


ii: 


Kri(li.>-rii,  and  Hiitlcr  consider  tlu'm  to  be  nivxoma;   wliilo  J.  X.  ^lae 


tliat  the  cli 


til 


)t 


i.s  1101  iiiyxomatous,  hut 
that  of  simple  inllanunation.  He  says  that  the  ordinary  mucous  poly- 
pus is  an  (edematous  fihroma,  not  a  myxoma.  Jonathan  Wright  also, 
al'ter  extensive  niieroscopieni  exaiiiiniitions,  has  arrived  at  the  eon- 
cdusion  that  true  myxomata  are  never  found  within  tlx!  nasal  eiiam- 
bers,  and  that  the  growths  usually  called  t)y  this  name  are  simply 
the  results  of  chronic  intlammation.  lie  finds  that,  in  addition  to 
the  degeneration  of  the  stroma  and  tlii>  ledumatous  iMiiltralion  so 
generally  ])reseiit  in  nasal  ]iolypi.  there  are  also  occasionally  hyaline 
bodies  (U*  berries.  They  are  conlimd  ;dmo>t  entirely  to  the  struma, 
and  vai'y  in  sixe  from  that  of  a  round,  white  blood-cell  to  three  or 
four  limes  thiU  dianiclci'.  "'riii-c  liodirs  are  ilivide(l  symmetrically 
by  sulri,  wiiicli  I'clracicd  the  light  strongly  into  lobules.  comiM'essed 
into  polygonal  shapes.  a]i|iarently  liy  a  limiting  membrane""  (donatlian 
Wright)?' 

Swain  has  proved  histologically  that  ]tolypi  having  surface  cor- 
rugations contained  a  lari:-e  amount  of  fibrous  tissue,  and  that,  whether 
in  their  origin  they  had  a  purulent  basic  foumlatioTi  or  not,  no  bacilli, 
cocci,  or  jiarasitic  bodies  seemeil  to  be  present  in  their  tis-ue.  Swain's 
observations  seem  1o  have  brought  out  an  addifiomil  fad:  that  tiie 
histological  character  of  the  polyp  beais  a  direct  relation  to  the 
density  of  the  tissue  upon  which  it  grows,  lie  also  believes  their 
origin  to  be  inflammatory,  invohing  the  pre -existence  of  an  hyper- 
trophic condition  of  the  mucous   membrane. 

Xotwithsfaiiding  dilferences  of  opinion  upon  fundamental  ])rin- 
ciplcs,  there  are  certain  pathological  comlitifuis  in  which  all  agree. 
The  external  surface  of  the  polypus  is  composed  of  an  epithelial  layer 
similar  to  that  of  the  ordinary  mucosa;  it  may  b(,'  mixe(l  in  character, 
or  either  s((uamons  or  ciliated,  according  to  circumstances  ami  situa- 
tion. Within  this  there  is  hypertrophy  of  the  stnu'tuial  elements 
of  the  mucous  mem!)rane  and  connective  tissue,  giving  a  fine  reticular 
frame-work,  the  me.<lies  of  which  are  filled  with  semifluid  mucin 
and  leucocytes.  Cilandular  tissue  may  be  present,  but  there  is  usually 
a  minimum  of  vascular  eh  nients  (l-'ig.  (!'?). 

The  site  of  attachment  is  usu.illy  the  internal  surface  of  the 
middle  turbinated.  It  may  be  around  the  margin  of  the  ostium 
maxillaro  or  along  the  whole  of  the  lower  border  of  the  bone.  Some- 
times they  are  attached  to  the  inferior  turbinated  and  occasionally  to 
the  septum;   but  these  instances  are  rare. 


Mi 


i 

tl 

1 

- 

1 

:  i 

i 

W: 

■i 

! 

■ 

i 

'i 
.i 

1- 

I 


n 


1  :  f 


118 


]>isi:.\si;>  Ob'  Tin;  nasal  passaciks. 


Etiology.— Altlioii'ili  tliis  sulijoft  lias  engaged  tlio  atteiiliou  of 
so  many  keen  ()l)servers,  as  has  already  been  said,  they  do  not  all 
agree.  The  probability  is  tliat  there  are  many  causes  which  may  lead 
to  tlic  develoinnciit  oi'  this  disease'.    'I'he  fact  tliat  tiie  mucous  mem- 


Fi}T.  02. — ]\Iici'os(.M)]ue-iil  scctiuii  of  iitusal  iiolypus  ("ilMI  (lianiptors). 
a,  Stratified  ciliated  I'liitlicliiini.  h.  I'cticular  fraino-work.  c,  rolyiiuclear 
leiic'Ot'ylo.  (/,  Yascular  iciitic.  c,  liadiaUiig  blood-vessels.  (Aulliov'a 
speeiiDcn  by  ]?ensley.) 

brane  of  tlie  middle  turbinated  is  of  softer  and  more  delicate  con- 
sistency than  that  of  the  lower,  and  composed  of  a  liner  reticular  tis- 
sue, may  make  it  more  liable  to  this  so-called  myxomatous  hyper- 
trophy.    In  a  normal  condition  the  tissues  of  the  middle  turbinateds 


NASAL    rOLYl'l. 


Hit 


are  in  constant  condition  of  scroud  oxo.sniosis.  The  inenibrano  in 
some  cases  may  be  easily  overdistended,  and,  if  from  any  cause  in- 
liibition  is  lost  at  a  given  ])oinl,  ibere  is  notiiin^if  to  prevent  tlie  dis- 
tension increasinf?,  with  proliferation  of  cell-elem(>nts. 

Woakes  believes  the  large  majority  of  cases  to  be  tlie  result  of 
necrosing  etlimoiditis,  while  (iriinwald  considers  the  formation  of 
polypi  to  be  secondary  to  enij)yema  of  tiio  accessory  cavities,  ^fc- 
]Jride  considers  tbcm  to  be  simply  (edematous  iiljromaia,  to  be  dis- 
tinguished from  papillonnita  by  their  density,  color,  and  site  of  origin, 
but  to  \)e  the  same  in  character  and  cause.  Zuckerkandl  suggests  that 
they  originate  as  adenomata,  but  that  during  development  some  of 
the  ducts  become  occluded,  resulting  in  myxomatous  (le_  luM'ation  of 
glandular  tissue.  Somewliat  in  opposition  to  all  these  views,  Jonathan 
Wright  and  Swain,  of  this  continent,  nuiintain  that  the  disease  is,  in 
all  cases,  a  result  of  chronic  inllammation  of  the  mucous  membrane. 

]My  own  conviction,  based  on  i)ersonal  clinical  experience,  is  that 
the  etiology  cannot  be  contined  to  any  one  cause.  In  the  large  ma- 
jority of  cases  that  I  have  seen,  where  the  polypi  were  large  and 
numerous,  there  was  no  sinous  disease.  On  the  other  hand,  cases  of 
antral  disease  that  1  have  attended  were  usually  alfected  also  with 
polypi  of  tlie  adjoining  middle  turbinated;  but  these  polypi  were 
always  small,  and  after  the  healing  of  the  sinus  the  poly])i  ceased  to 
return.  Hence  they  were  ]mrely  secondary  results,  quite  dilferent 
from  mulliple  myomatous  disease. 

Nasal  ])olypi  are  ^^nid  to  occur  more  frequently  among  males  tiuin 
females.  Tliey  rarely  occur  in  early  life,  although  one  of  the  most 
severe  cases  1  ever  saw  occurred  in  a  little  girl  aged  7  years,  from 
whom  1  removed  about  twenty  from  the  two  nostrils;  Fig.  03  gives 
a  microsco])ical  section.  Her  mother  stated  that  she  had  been 
troubled  with  them  from  the  age  of  two  and  a  half  years;  and  that 
for  more  than  a  year  after  that  she  was  un(h'r  the  constant  care  of 
a  specialist,  who  reniovt'd  tiiem  as  rapidly  as  they  apjieared.  This 
case,  I  think,  was  undoubtedly  congenital.  The  rarity  of  these  cases 
is  evident  from  ]\lour(!'s  statistics,  for,  out  of  10,5'v'O  cases  of  na.-^al 
polypi,  only  o  occurred  among  children.  This  is  strikingly  brought 
out  by  Dtmbar  Roy  in  an  aide  article  reporting  a  case. 

Symptomatology. — Two  noted  authors  give  directly  opposite 
statements  as  to  tirst  sym})toms.  iiosworth  says:  "The  first  and 
earliest  symptom  is  tense  irritation  in  the  u])per  air-passages  of  the 
cavity,  manifesting  itself  in  more  or  less  violent  attacks  of  sneezing. 


r.'d 


l)isi;.\si:s  OF  TilK   N.\s,\[.   i'.\s>.\(ii:s. 


'I 


li    i 


:■! 


ili!^ 


:!  t         i,| 


{U'((iiii|iiiiiic'il  uitli  wiitciy  (liscliiirirc."'  liCimnx  Urdwiic  says:  '"Sucoz- 
in<^'  is  seldom  cxhiljitcd,  imiiiuiiity  irom  tliis  tlisajii't'cnlili'  symptom 
licinir  (loiihrk'ss  due  In  a  liluiitiiii,'  ol'  the  sciisiliility  of  tlii.'  iktvc- 
c'iidiii<rs." 

I  111  ink  till'  fact  is  tiiat  wo  so  rarely  see  cases  of  nasal  polypi 
when  tlicy  cdinmence  to  lonn  tliat  wo  cannot  tell  wi\ellier  they  are 
accniiipanied  liy  sneezin.ti'  or  net.  When  tiie  jtatietit  first  presents 
liiiiisclf  for  treatii'.ent,  it  is  usually  for  the  relief  of  nnilateral  catarrh, 
associated  witli  more  or  less  nasal  stenosis  and  frontal  coniprossion. 
Jn  some  instances  we  are  asidnislied  at  the  small  amonnt  of  apparent 


Fig.  0.3.^ — Microscojiical  sfclioii  of  iia.sal  polypus  from  ii  cliild  7  yo.iis  old. 
(Aullior"s  sppciinen  by  Beiislcy.) 

distress  which  larfre  masses  of  polypi  will  produce.  The  reason  of 
this  is  obvious:  they  always  form  in  the  middle  tur1)inated  region 
and  by  their  presence  and  pressure  expand  the  upjier  ])ortions  of  the 
nasal  fossa\  By  this  means  the  lower  tnrhinal  region  is  also  ex- 
l)andcd,  giving  com])ensatory  siiace;  and  it  is  not  imtil  tliey  are 
large  enough  to  drop  dcwvnward  that  breathing  is  interfered  with. 

The  sense  of  smell  is  likewise  seriously  affected  in  the  majority 
of  cases. 

Xot  infrequently  nasal  polypi  give  rise  to  reflex  disturbances. 
This  is  particularly  the  case  with  hay  fever  and  asthma;  and  the 
truth  of  the  statement  is  proved  by  the  history  of  numerous  cases 


NASA  I,  I'oi.vrr. 


rn 


of 
on 
he 

'X- 

irc 

[ty 

Ics. 
Ihe 

pes 


in  wliici)  tlici-c  ;ill'i'(ti(iiis  luivc  liccii  rclicvccl  liy  tlic  removal  ot'  IIr' 
oH'cndiiiii-  canst'.  Ain'iiscxia.  or  hick  of  |iii\vcr  nl'  coiicciili'atidii,  is  also 
sonu'tinu's  a  roiilt. 

'I'lic  (icuiar  and  aural  (lisliirlianfos  imltifcd  liy  the  prossuro  of 
nasal  |i(ily|ii  arc  not  m)  iiuicli  ul"  a  rcllcx  character  as  (luiii^  to  direct 
])rL'ssiire  ii])on  couti.uuous  structures  in  the  ease  of  the  eye  and  inter- 
ference with  the  noi'nial  cdiidition  id'  the  luistachian  tniu!  in  thai  of 
the  car. 

Diagnosis. --This  can  only  lie  made  hy  direct  inspeclion;  and, 
no  matter  how  easily  seen  the  growth  may  he,  it  is  hetter  to  make  a 
thoroiiiih  examination  by  rellected  liiiht.  'I'o  the  exjierienced  ohservei' 
scarcely  anythiuii'  else  can  In-  mistaken  I'm'  polypus.  To  the  inexperi- 
enced it  is  widely  dill'ereni.  Sometimes  the  polypi  aie  deeply  seated 
and  may  he  hidden  liy  a  derornud  septum,  t>v  the  inlerior  turhinated 
may  lie  so  enlai',L!t'(l  as  to  hide  them  friun  view.  The  application  ol'  a 
solution  of  cocaine  will,  in  a  few  nnnutes,  i-cmovc  thoe  dilliculties 
and  facilitate  examination.  The  liluish-^'i'ay  color  and  shiniuLr  sur- 
faces of  the  polypi  slmuld  easily  lie  recoL;uized.  Then  hy  u-in.Li'  the 
probe  they  can  readily  he  moved  and  thcii'  >ui'l'aces  indeiiled.  When 
tlie  p(dypi  extend  baekward  into  the  posteiior  choana",  they  can  always 
be  examined  by  aid  of  the  ])ost-rhinal  mirror.  Ifero.  on  aecount  of  tho 
color  of  tho  two  heing  nearly  tin'  same,  liyportrophy  of  the  posterior 
(  iid  of  the  inferior  turbinated  might  be  mistaken  foi'  poly]ius:  the 
corrngated  surface  of  the  former,  however,  as  compared  with  the 
smooth  shining  surfaces  of  tlu;  latter,  should  make  the  diagno.sis 
certain. 

Prognosis. — Xa.sal  polypi  involve  Init  little  danger  to  life.  They 
proflnoe,  however,  a  great  deal  of  physical  distress,  while  thoy  ex- 
liibit  little,  if  any,  tendency  toward  spontaneous  arrest  of  develojunent. 
While  a  catarrhal  condition  (d'  the  mucous  mendiranes  is  ]H'oduced 
liy  their  presence,  the  most  serious  n^sidts  that  may  be  expected  ai'c 
the  development  (d'  hay  fever  and  asthma  by  rellex  iu>rvous  action. 
To  these  might  be  added  destruction  of  the  sense  of  smtdl.  and,  also. 
what  is  more  serious,  impairment  of  hearing  caused  by  pressure  of  the 
post-]iharyngeal  ]iolypi  on  the  Kustachian  tubes. 

The  longer  the  disease  is  neglected,  tho  larger,  tho  more  numer- 
ous, and  the  more  ]irolific  do  the  growths  become.  It  is  also  a  disease 
which  ha.-  a  strong  tendency  to  return.  T.et  the  ]ioly])i  be  removed 
as  perfectly  as  seems  possible,  and  in  many  instances  a  few  months 
will  snflfico  to  have  a  now  crop  appear,  like  young  grapes  in  an  old 


I 

HI' 


1)|si:a-i:s  ov   i  ii 


\  \-  \  I.  i'.\>sA(ii;s. 


III-'.' 


viiii'vanl.     Tlic  niily  \vi>c  pljiii  i,-  In  ki'i'p  ihc^c  (•;!<('>  iimli'i'  cnii.-tiint 

nlisi'l  Vill  iiill.   iMliI    liV    (iircllll    Opl'lill  l\i'    I  l-i'ill  llli'lll     In    r(|llil\('    the    |l(i|v|IS 

as   I'iisi  as  llicv   1(11111.      In   llii.s  way   iiiaiiy  (.iin*   in    ilic  end  ran    lie 

iK'COUiplisllL'd. 

Treatment. — C'nmiilctc  rcmo\al  of  liio  neoplasms  is  the  only 
])ro|u'r  Ileal iiK'iit.  wlicllu'r  accomplishod  by  alilation  or  (Tostniction, 
or  both,  {''niiiicrly  tlic  application  of  n>ti-in<xt'iil-:  in  the  1'onn  of 
powders  and  sjirays  to  iIk'  siiriacrs  of  llic  polypi  was  jar^rly  prat'- 
liced,  tnit,  beiiii;  jtractically  nsoless,  it  lias  been  aliandoncd. 

Removal  by  cold  snare  or  forceps,  and  to  destroy  thciii  by  gal- 
vatincantery  or  electrolysis  are  the  methods  now  in  use.  Of  these  the 
cold  snare  has  in  every  way  the  preference.  Tt  is  more  widely  used 
than  any  other  instrument,  and  it  iiroduees  tlu'  best  and  most  lasting; 
results;  it  is  indorsed  by  such  men  as  ]\Ioure,  lieiinox  Browne,  l^os- 
worth,   Sliurly,    Delavan,  Sehech,  MaeKeiizie.  and   a   host   of   others 

<Fi,!,rs.  ;?;i,  -aV,  I]'},  ;'.(;) 


Kijr.  (!4.     Hliikf's  I'lU'  pciJN  jius  siiiiii'. 

Jarvis  was  the  liist  to  introduce  ablation  by  this  instrument. 
Since  then  the  sieel-wire  snare  has  underiione  many  nio(li(icati(nis, 
and  at  the  i)resent  time  there  are  many  varieties  in  the  market. 

The  simpler  the  instrument  is.  the  shorter  its  shaft  and  handle, 
and  the  more  easily  it  can  be  manipulated,  the  better.  The  chief 
points  in  selection  are  io  have  the  instrument  light  and  strouix;  with 
the  handle  jilaced  at  an  angle  with  th(^  shaft,  so  as  not  to  oiiscurc 
the  vision  of  the  jiarts  while  operatinsx;  and  to  have  it  so  hung  that 
in  the  large  majority  of  cases  it  can  be  manipulated  for  the  removal 
•of  the  polypus  entirely  by  the  one  hand. 

Personally  1  liav(!  in  my  armamentarium  a  number  of  expensive 
instruments  highly  recommended.  They  are  haiulsomc.  highly 
polished,  and  indir'ative  of  scientific  knowledge  and  skill  on  the  part 
of  their  inventors.  But  I  rarely  use  them.  I  have  iried  them  over 
and  over  again  on  ditferent  occasions;  but  they  are  all  so  cumbersome 
f.nd  unsatisfactory  that  they  lie  in  the  case,  simply  to  be  looked  at; 


H 


NAS.M,    rOI.Yl'l. 


133 


1111(1  1  lilt  all  my  work  now  with  two  or  tlirt'c  eiir-|toly|ui.-  .-nan'-;  of 
almost  till!  siuno  pattern.  I  liml  tln'iii  iiuitr  rapaltli'  of  gras^ping  and 
rrnioving  tlit'  lai'gr>t  iimmiI  pol\'pii.s  cvrii  when  lilliiii:  the  postcrioi' 
clioana.  Tlicy  arc  almost  identical  in  form  ami  -i/.c  with  IMakc's 
cai'-|io!y|iii>  .-11,11'c  (Fig.  <>  I ). 

Ill  opcrntiiig  cocaine  should  always  l)c  used,  iiot  only  to  aiia'S- 
thetize  the  parts  fully,  hut  al.«o  to  .-liriiik  the  tissues  and  render  the 
vision  of  the  fossa  as  perfect  as  po.-silde.  it  is  lust  to  throw  in  a 
■l-per-ccnt.  solution  first,  and  llicn  apiijy  a  lii-  lU'  lo-pcr-ceiit.  solulion 
liy  means  of  a  cotton-liolder. 

fn  adjusting  the  snare  ca''"  should  lie  taken  not  to  have  the 
loop  much  larger  than  the  circumference  of  the  polyp  to  he  inclosed, 
'riicii,  as  the  attachment  is  always  on  the  external,  and  not  in  the 
septal,  side,  the  lower  rim  of  the  loop  should  he  dulward  as  it  is 
passed  into  the  nasal  rw  ity  aiul  slipped  under  the  lower  margin  of 
tile  ])oly]uis.  r.y  a  gei'.le  hack-and-l'orward  movement  and  gradual 
tightening  of  the  loop,  it  can  usually  he  slipped  up  to  the  neck  of 
the  polyims:  then  the  wire  is  drawn  home  and  hy  traction  the  hody 
removod. 

This  is  only  a  general  rule  id'  operation,  and  must  he  modiiiud  in 
detail  according  to  the  numiier  and  jiosilions  of  the  dill'erent  ])<dy|)i 
and  the  e.\])erieiice  of  the  operator.  After  cleansing  the  fossa  of  dis- 
charges that  may  occur,  the  routine  may  he  repeated  over  and  over 
again  at  the  one  sitting,  until  all  that  are  visihle  are  removed,  or  until 
it  seems  advisahle  to  postpone  the  conclusion  of  the  work.  As  a 
rule,  the  liivmorhage  is  slight,  hut  occasionally  it  may  he  more  severe; 
and  in  some  cases  tampons  might  retpiire  to  he  inserted  to  hasten 
its  control.  1  have  never,  however,  seen  a  case  where  this  was  neces- 
sary. 

ITow  thoroughly  the  removal  of  the  visilde  polypi  j'roni  one  or 
hotli  nostrils  at  the  one.  sitting  may  he  acco.  »!ished  depends  a  good 
deal  on  the  ahility  of  the  patient  to  stand  the  combined  eifects  id'  the 
cocaine  and  the  ojierative  treatment.  In  any  ease  I  believe  it  is 
better  to  have  the  patient  return  at  intervals  of  two  or  three  day.s  regu- 
larly until  all  the  poly])i  are  extracted.  T  have  freipiently  seen  case.s 
where  I  liav(,'  taken  away  all  that  1  could  see  on  the  one  day,  and  on 
the  reappearance  of  the  ])atient,  forty-eight  hours  later,  another  si?ries 
were  visible  in  the  lower  part  of  the  middle  meatus.  These  were 
not  of  new  formation;  hut  liad  merely  availed  them.selves  of  tlie  open 
Sjiace  produced  by  the  ju'evious  evulsion  and  by  gravitation  and  ])re.'!s- 


If; 


l-.'l 


msKAsi'.s  oi'   iiii:   NASAi.   i'AssAt;i;s. 


I: 


I!, 


lire  11(1111  ;il)n\c  luiil  iiiiuli'  llu'iii.-rlvt.'s  visil)lf.  Some  jiiillmritics  advise 
to  \v;iit  ii  week  liclnrr  ((ptTiitiii;,'  tlxi  sfcoiul  liiiir.  Wliv  .^lioiild  tliis 
he  ddiif!"'  'I'lic  |)iiti('nl  (ilicii  cniiit'S  lifiy  or  one  hundred  niile.>  to  lie 
relieved  (d'  liis  n.i.-iil  lidnlde.  'I'iine  is  prei  ions  to  iiiin;  iind  it  would 
seem  to  lie  our  duly  lo  relieve  liiin  iis  llioroiijiiily  as  |tossil)le  during; 
the  liniiti'd  period  at  his  disposal;  and  we  may  he  ahle  to  do  this  by 
operalinji:  on  alteinate  days  until  the  work  he  a('e()m])lished.  provided 
tlial  the  reaction  I'loni  eaeh  operation  has  sid)>i(h'(l  hel'ore'  tlu'  next 
one  is  done,  hiii'in;^'  the  intervals  hetween  (tperations  1  have  ioiind 
my  patients  rendered  niueh  nior"  eomt'orlahle  liy  the  repeated  use  of 
a  spray  (d'  simple  allxdeiie. 

When  tlu'  nostrils  aic  pretty  thoroughly  cleansed  id'  p*  lypi,  it 
is  advisahle  to  aiiain  iipply  cocaine:  and,  n])on  dryin^f  the  parts,  little 
rrajrineiits  and  slumps  oi'  polypi  may  still  he  vi>ihle.  'i'lu'se  should 
he  tou(dii(l  with  ilic  uahaiuicaulery:  ami  it  can  he  done  with  l»ut 
sliijht  injury  to  the  siirroiiuding  mucosa.  Tlu'  healiim'  is  rapid  ami 
attended  by  little  or  no  discomfort. 

Bosw'orth  says  that:  '"If  we  tiHU'ou<;hly  extirpate  the  grc 
they  do  not  recur."  '{"his  is  contrary  to  my  own  experience  aiiu  lU 
that  (d'  a  lar;;'e  numln'i'  of  rliin(do,irists.  Sonu'  operators  are  more 
skillful  and  more  successful  than  ollu'r>:  hut,  as  a  ride,  you  may  re- 
move eveiy  ve.-li^e  id'  polypus  that  can  he  found,  you  may  ahlate 
completely  ami  watch  the  case  for  weeks  or  months  withiuil  the 
sliiihtest  apparent  return,  hut  let  two  or  three  years  pa>s  hy.  particu- 
larly in  youu^  people,  withoid  any  treatment,  and  in  a  lai'uc  numher 
(d'  cases,  upon  examination,  you  will  tind  a  reforuuilion  of  the 
lirowths.  'i'his  may  not  lie  on  account  of  iiicomi)lete  extirpation: 
hut  from  the  fact  that,  although  you  can  ei'adieate  the  disease,  you 
may  not   lie  aide  to  erailicati'  the  innate  Icndency  to  its  development. 

Casselherry  strongly  favius  removal  of  the  anti'fior  I'lul  of  the 
middle  tiirhinated  l»y  scissors,  foiceps.  and  curette,  when  the  polypi 
form,  as  they  friMpiently  do.  directly  ai'ound  the  hiatus  semilunaris. 
I'his  uives  much  iireater  freeilom  of  access  to  the  bases  of  the  [lolypi. 
and    periiiil>  of   nioi'e  Ihorouiih   eradication. 

1  do  not  uieaii  to  say  that  this  disease  cannot  be  curetl.  for  F 
believe  it  can:  hut  that,  to  thoroughly  destroy  the  tendency,  each 
case  slioidd  he  seen  often  eiiou>;li  to  ni|)  the  buds  as  they  form,  and 
by  this  nu'aiis  eventually  to  hreak  up  the  habit. 

The  dilliculty  is  that  patients  experience  such  complete  and 
trrafifyini;  reliid'  after  thorough  operative  treatment  that  they  do  not 


I 

IP 


NAS.M,    l■(l|.^  I'l. 


1  •.'.". 


tiikc  (,'();fnizaiii'i'  ui'  the  .-lnw  rctiiin.  ami  Irciiui'iilly  jmU  oil'  lln'  \i.'>it 
t<t  the  siir^'cnii  iiiiiil  :i  liir.i^c  iiiiiiilirr  of  pulvpi   have  a;.faiii  (lt'Vfln|ici|. 

Tilt'  stH-'ond  iiii'llinil  (iT  ii'cal  inciit,  ilial  <i|'  rviiUinn  liy  l'iiicc|is,  i- 
tlic  oldest  iiicthod  oT  opciativi'  ]irucc(liiic.  and  is  still  lar^ifly  iirac- 
liccd.  Many  rmiiis  ol'  tliis  iii>tnmi('iil  have  liccii  devised,  'i'lie  lilades 
should  he  narrow  and  stronLT.  as  well  as  -Jcrrated.  ny  tnoihcd.  and  set 
at  a  similar  an;:le  to  the  na-al  saw  and  |inly|in>-»iiare  and  I'lii'  the 
same  reasons.  Seller'^  t  nhe-toree|is  are  aUu  »aid  in  --erxe  a  ;^niu\  piir- 
posf. 

The  chief  ohji'ction  to  the  I'oreeps  o|ieratiiiii  is  the  injury  .-o  likely 
to  he  inilieted  upon  the  mueoiis  nieudiraiie  hy  its  um'I  a  consider- 
ation so  lar,i;('ly  ahsent  in  the  carerul  u.«e  of  the  -naie.  If  the  suri^eon 
decido  to  operate  with  the  fnrccp.-,  it  hcc(imc«  hi«  imperati\e  duty 
to  e\crci>e  the  ^'reatest  care  in  nrder  to  produce  a  minimum  of  injury. 

in  operating;',  after  cocaini/alion.  aich'd  hy  -pcculum  ami  mirror, 
the  forccjis  should  he  closed  and  ,u'ently  in-erled  until  the  neck  of 
the  polypii.-  i.«  reai'hcil  ami  carefully  seized.  Then  hy  a  tui-tin;:'  rotary 
inotioM  it  is  detacheil  and  withdrawn.  'I'he  M|ieratioii  is  to  he  re- 
peated until  all  the  polypi  ai'c  removed.  There  is  nuu'e  tearinji  in 
(his  operation  than  with  the  snare  and  conseqiuMitly  more  hleedin;.;'. 
So  that,  as  a  rule,  a  smaller  iiumher  can  he  removed  at  one  .sitlinu'. 

The  <;alvanoeaulery-.-iiare  had  nuuieriuis  ailvoeates  anioiii;  the 
earlier  writei's  for  the  elVeetiial  removal  of  nasal  polypi.  NOItoliui, 
^liehel.  liriin.-.  and  others  heiuii'  earnest  advocates  (d'  the  method. 
Later  writers,  however,  do  not  approve  of  it.  the  chi(d'  ohjectimi  heinu- 
the  <lilllcnlty  of  adjustinu'  the  soft  ami  |)liahle  platiiinm  wire  to  the 
iieek  of  the  polypus.  In  place  of  it  the  cla>tic  spring  of  the  cold-steel 
wire   has   found   almost    univeisal   faviu'. 

One  other  method  of  treatment  mu>t  he  ineiil'oncd  which  ha~ 
heeii  received  with  some  favoi'  hy  seveial  recent  writers;  this  is  treat- 
ment hy  electrolysis.  Two  methods  of  applieatio:;  are  advocated:  one 
is  to  attach  till'  po.-iti\c  pole  of  the  hattei'y  lo  a  neeille  to  he  in-erted 
into  the  polypus,  wliile  the  nciiiilivc  pole  with  ^ponu'c  electrode  is 
])laced  over  the  nose;  the  other  is  to  pa-s  hoih  needles  into  ilie  poly- 
]ms  side  hy  side.  The  current  in  each  ca-c  shoidd  lie  coiitiniied  foi' 
ten  or  lifteeii  iniiuites  at  each  sittine-.  'I'he  proeos  is  a  \ciy  tedious 
one.  and  for  this  diseasi'  of  douhtful  utility. 


I 

: 


I 


Jl 


1 

-■ -■-- 

— -.,. .. 

li 

;    .  :  i 

i:  ■? 

CIIAI'TKli  XIX. 


papillo:ma. 

As  ALRi-APY  staled  ill  the  prooodiiig  chaptor,^  the  palli(ilo,<iical 
dill'creiu'o  \n  tlio  rnnstnu'tion  of  na.'^al  jmlypus  and  nasal  papilh)nia 
is  very  sli<;ht.  The  elementary  tissues  are  the  same  in  each,  the  dif- 
ference, accord iiiii'  to  ]\Icr>ride,  lieiiiir  dependent  very  nuich  iijion 
density  of  construction  and  site  of  attachment,  their  microscopical 
characters  heina'  very  much  alike.  The  pa])illoma  is  the  result  of  pro- 
liferation of  epithelial  and  connective-tissue  elements.  When  found 
near  the  entrance  of  the  nn,«tril,  the  growth  is  firm  and  dense  in 
structure  and  cinered  with  sipiamous  epithelial  cells.  When  deeper 
within  the  cavity,  tlie  covering  is  of  columnar  C(dls  and  the  papilloma 
is  of  softer  texture  (nopmann). 

The  usual  site  is  the  anterior  jiortion  of  the  nostril,  either  upon 
the  inferior  turbinated,  the  septum,  or  the  floor  of  the  nose.  Tliey 
are  supposed  to  be  caused  by  irritation  of  one  form  or  another.  Still, 
as  they  resemble  cutaneous  warts  in  method  of  growth,  as  well  as 
structure,  it  is  dillicult  to  trace  the  etiology. 

They  are  not  of  fre(pient  occurreiu  j,  although  much  has  been 
written  about  them.  Their  growth  is  slow  and  painless,  and  fre- 
([uently  the  only  knowledge  the  patient  has  of  their  existence  is 
from  digital  examination,  'i'lie  annoyance  which  the  discovery  has 
produced  may  induce  the  patient  to  have  them  removed.  Sometimes, 
like  their  congcmers,  warts  on  the  hands  or  face,  they  may  appear  in 
numbers;  and  produce  a  certain  amount  of  stenosis,  with  local  irrita- 
tion and  muco-purulent  discharge. 

In  regard  to  prognosis,  operation  is  said  to  liave  been  followed 
by  death  in  two  cases.  In  Ward's  cas(^  the  patient  died  of  pneumonia 
twelve  days  later,  though  what  connection  existed  between  the  two 
])henomena  we  are  left  to  conjecture.  In  A'crneuiTs  case  death 
seemed  to  have  resulted  from  an  extension  -f  the  tumor.  With  these 
exceptions,  the  results  of  ojierative  treatment  have  apparently  always 
ho'Ti  successful. 

Treatment. — This  is  simply  removal   of  the  growth,  either  by 


I'Al'IM.OMA. 


V27 


snare,  scissors,  or  knil'c.  The  iiiiiin  olijc  i-  o  ri'innve  the  neoplasm 
in  its  entirety  and  with  as  little  irritation  '■.,  the  surrounding  mucosa 
as  possible.  In  the  majority  ol'  instances  this  can  be  act oniplished  by 
means  of  the  cold-wire  snare.  As  a  rule,  no  after-treatment  is  re- 
(luired.  If,  alter  ablation,  any  prominent  tissue  is  left  or  the  removal 
is  incomplete,  the  base  should  be  touched  with  the  galvanoeaufery. 
When  near  the  margin  of  the  nostril,  it  would  l)e  well  to  apply  vaselin 
occasionally  for  a  day  or  two  to  allay  irritation. 

In  my  own  practice  I  have  seen  but  one  case.  This  occurred  in 
a  lady  aged  ."i.")  years.  It  was  located  on  the  lloor  of  the  right  inferior 
meatus,  and  would  occasionally  bleed,  ll  was  cliiiped  oif  with  scis- 
soi's  and  wilhoul  u>ing  cocaine,  and  healed  without  furllier  treatment. 

In  the  majority  ol  cases  it  would  be  iietter  to  use  a  local  aiues- 
thetic   l)erore   o]ierating. 


1)11.  \ii;i!  At.  TiMoL's  {)[■■  nil,  Si;i'HM. 

I'eglcr  {■/ (lit null  of  Ldri/iiiitiliKiii.  riJilnoloijij,  and  Ololiiiji/,  October, 
1S!)S)  divides  these  growths  into  two  varieties:  the  lymphoid  and  the 
erectile.  'I'lieif  eliiei'  interest  lies  in  tlieir  etiological  relationship  to 
nasal  obstruction,  paresis  of  the  soft  palate,  and  sininalic  dyslalia,  or 
affections  of  speech. 

Of  the  lymphoid  variety  the  aiitlun'  report-  one  case.  This  con- 
sisted of  a  growth  on  each  side  of  the  septum,  a!i<uit  three  millimetres 
from  the  posterior  border.  The  fniuors  wen^  attached  by  a  broad, 
tough  pedicle,  and  projected  into  the  naso-pbaryn.v.  They  were  o\al 
in  shape,  pale  in  color,  and  mammillated  on  the  surface.  Microscop- 
ically they  con.sisted  solely  of  lymphoid  tissue,  iiuapsuled  by  ciliated 
epithelium.  There  were  no  adenoids,  but  large  hypertrophies  of  the 
ndddle  and  inferior  tnrbinateds  were  ])resent. 

1"he  (M'cclile  \ariety  appearc]  as  parallel  longitudinal  ridges,  ex- 
lending  along  the  se|)lum  from  before  backward  at  the  level  of  the 
tubercle.  "^Ibey,  too,  are  br>'ad-based,  pink  in  color,  and  sometimes 
lobulated.  .Microscoj)ically  they  are  composed  of  erectile  tissue,  min- 
gled with  masses  of  lymphoid  cells. 

The  treatment  o\'  the  lymphoid  (iimors  was  removal  by  cold  snare 
and  spokeshave,  aided  l)y  the  linger  in  the  naso-pharyn.x.  'J'he  erectile 
growths  were  excised  by  means  of  a  curved,  probe-jiointed  tonsil-knife, 
the  snare  being  us(>d  to  engage  what  had  escaped  abscission. 


I  i.i 


"  m\ 


m 


Iljrt 


I'Wk 


CHAPTKU  XX. 


FIBUOAIA. 


'll'l 


I: 


The  nifijority  of  cases  of  fibroma  alTcctiiig  the  air-passages  are 
to  be  found  in  the  naso-pharynx.  iStill,  an  examination  of  tlie  liter- 
ature upon  the  suljjecl  will  prove  tluit  it  sometimes  does  oecur 
witliin  the  nasal  cavities,  and  the  reports  of  something  like  fifty  cases 
have  been  published. 

Pathology. — Fibroma,  wherever  found,  presents  the  same  essen- 
tial ])atliologieal  features.  Its  chief  constituents  consist  of  close- 
grained  fibrous  tissue,  witli  stellate  cells  scattered  between  the  bundles. 
The  fibrous  tissue  is  chiefly  wliite,  with  yellow,  elastic  fibres  inter- 
lacing through  it.  l>ilbroth  has  shown  that  the  starting-point  of 
development  is  in  the  nerve-sheaths  and  walls  of  the  small  arteries. 
As  the  growth  develo])s,  the  nerves  shrink  ;  way,  while  the  arteries 
become  enlarged.  This  will  account  for  the  (omparative  insensibility 
of  nasal  fibroma,  together  with  its  tendency  t.)  re[)ealed  Imenijrrhages. 
Sometimes  myxofibroma  appears  from  the  first,  and  the  excessive 
arterial  supply  may.  in  others,  lead  to  formation  of  angiofibroma. 

Etiology. — 'i'iie  rich  supply  of  nerves  aiul  blood-vessels  within 
the  nose  may  have  a  causative  relation  in  the  etiology  of  this  disease, 
particularly  as  it  is  in  the  nerve-sheaths  and  advcntifia  of  fhe  arteries 
that  it  makes  its  first  manifestation.  Traumatism  is,  in  some  case.s, 
the  exciting  cause.  It  occurs  more  fre(]uently  among  males  than 
lemales,  and  it  is  most  prevalent  during  the  earlier  years  of  life, — 
say,  between  the  ages  of  15  and  4(i  years. — though  no  period  of  life 
is  exempt.  In  Jol)son  Home's  case  tlie  patient  was  a  woman  aged 
TO  years,  while  Sikkel's  ca<e  was  congenital,  lieiiig  pi'cscnt  at  the  birth 
of  the  child. 

Symptomatology. — The  chief  symjitoms  are  gradually-increasing 
stenosis  of  one  nasal  fossa,  atteiuled  l)y  frequent  luT'morrhages.  and 
occurring  during  the  earlier  years  of  life.  The  closure  of  fhe  nasal 
cavity  increases  as  a  result  of  the  growth  of  the  neoplasm.  The 
attacks  of  bleeding  are  sometimes  very  frequent  as  well  as  persistent. 
The  sliglitest  touch  U]ion  the  tumor  may  give  rise  to  it. 

Other  symptoms,  the  result  of  ])ressure.  are  observed  as  fhe  dis- 


FIHHOMA. 


l-.*!» 


<'asi'  iulvanccr;.  Such  a.-  aiio^min.  I'loiii  coinprt^sioii  nf  the  oll'actni'y 
iK'i'vt'-filamcnts;  dcafiicfs,  Iroiii  closiuv  nt'  tlu'  Kiistacliiaii  luhi';  or 
c']ii|ili()ra,  iroiii  pros.siirt'  ii]Mm  the  lacnnial  duct.  Facial  ami  [lalaial 
<lct'(irniity  arc  also  frc(|iU'iUiy  ])rc>cnt   from  the  same  caii.-c. 

Diagnosis. —  M.xaiiiiiialion  with  the  nasal  spcciihuii  should  reveal 
tliu  front  siirfacc  of  the  tumor.  Application  of  cocaine  will  shrink 
the  surrounding  tissues,  and  after  removal  of  secretions  hy  the  cotlon- 
lioidcr  a  g(M)d  vision  should  he  ohtaineil.  'j'he  color  should  he  a  pale- 
rcddi.-li  ]md<,  some  parts  hrighter  in  color  and  ready  lo  hnrsl  with 
the  contain(!d  hlooci.  When  in  a  slate  of  (piiescence  and  unirritatcd. 
the  white,  fibrous  tissue  may,  in  some  cases,  he  seen  bi'nealli  the 
glistening  surface.  M'he  growth  is  u.-nally  -nuioih.  Inlndated,  and 
irregular  in  forir.  its  limits  well  delined.  and  its  attachment  sessiU'. 
'i'he  body  ol  the  growth  is  tirm  and  not  easily  moved,  though  touch- 
ing by  ih(!  jirobe  may  not  infrecpiently  ])roducc  luemorrliage.  The 
postcricn'  side  of  the  tumor  can  usually  l)e  e.xamiiu'd  by  aid  ol'  the 
rhinoscopic  mirror,  when  displacemenl  ol'  the  normal  tissue^  ma\ 
be  obseiveil,  as  a  result  of  the  enlargement  of  the  neoplasm. 

The  relentless  growth  of  (Ibroma  is  one  of  its  characteristics, 
iind  in  this  it  resembles  sarcoma,  i'lic  more  iiiegular  contoui',  with 
the  presence  of  greater  pain  and  a  larger  amount  of  surface-sloughing, 
should  di>tinguisli  the  lattc  but  it  will  reijuii'e  microscopiral  I'Muui- 
nation   to  complete  the   dia,i:i'  isiw. 

Prognosis. — Without  suci-essful  operation  the  rosidt  \\  dl  always 
be  unfavorable.  The  steady  advancement  •■''  tin'  gr<»u  -  upon  all  tiie 
surrounding  tissues,  muscles,  cartilages,  and  bunes.  ano  il-  nearness 
to  the  vital  points, — arti-i'ies,  nerve,-,  and  bi'aiii,—  I'cndcr  ,.  laial  re- 
.^ult  iiu'vitablc. 

With  operative  treatment  iriany  cases  have  jM^rinanenlly  recov- 
ered; and  when  the  tibroma  lan  be  entirely  removed  the  |)rognosis 
is  hopeful.  The  ojieration  itself,  however,  is  iu)t  witl  ut  danger. 
A    nundier  ot   case<   are    rei-oi'ded    in    which    dealb  directlv    the 

result,  and  in  most  (d  ihem  from  the  ha'nioi'rhage  ii-rli.  iil  the  limi 
of  the  operation. 

Treatment. — Local  treatment  by  \\;iy  of  >prays  and  powders  is 
useless  in  this  disease.  Klectndysis.  howevei'.  a-  reportei]  of  one  ease 
by  Tngals  and  another  by  the  writer.  lia>  been  u>i'i\  with  advantage  in 
reducing  the  size  of  the  growth  and  in  facilitating  nitu'c  radical  meas- 
ures.    Whether  or  not  it  can  be  made  availalde  for  complete  removal 


rcmaiir- 


to  1 


)e  seen. 


J  «;. 


130 


DISEASES    OF   TUK    XASAF.    PASSAOKS. 


Wlieii  tlic  tumor  ciiii  lie  (.'iiibraCLMl  hy  a  Cdlil-wirc  snare  or  tl\o 
galvanocaiitery-ecrasoiir  (Fiji.  37),  there  are  no  better  moan-  ot'  oper- 
ating at  our  di?p<jsal.  Of  the  two,  as  in  the  cas^e  of  nas^al  polypi, 
the  i^teel  wire  is  more  readily  adjusted  than  the  jtliahle  )>latinuin,  and 
iu  the  use  of  the  one  or  tiie  other  each  case  must  be  judged  upon  its 
merits.  The  slow  compression  of  the  steel  wire  will  probably  do 
more  for  the  prevention  of  hamiorrhage  thaii  the  more  rapid  adjust- 
ment of  the  cautery-snare,  allliough  the  latter  might  have  a  better 
efl'ect  in  destroying  the  base  of  tlie  tumor. 

Owing  to  the  broad,  sessile  base  which  so  often  oi(  urs,  Cassel- 
bcrry's  device,  of  notching  the  base  of  the  fibroma  at  each  side  by 
the  galvanocantery-knii'e  (Fig.  3(S),  and  then  adjusting  the  steel 
snare  into  the  notches  and  round  the  growth,  may  suit  some  of  these 
cases. 

Tn  some  cases  the  neoplasms  have  liocn  so  large  and  ditlicidt  to 
reach  that  the  surgeon  has  resorted  to  direct  dissection  by  operating 
upon  the  nose  or  througii  the  jialate  in  order  to  reach  the  seat  of  the 
disease. 

Still,  in  all  cases,  nn  matter  how  operated  on,  the  great  danger 
of  lia-morrhage  at  the  lime  has  to  be  met.  In  CJerdy"s  case  and  in 
Seiler's  both  died  on  the  table  from  tiiis  cause. 


Ill  ii  case  the  history  i)f  wliich  I  read  hcfurc  tlie  hiryngoliijjrical  M-ctiou 
(if  tlic  AiiuTican  Medical  Assnoiaticm  at  HaltiiiKiic.  in  ISito.  the  j)atient  alnu>st 
bled  to  death  in  my  ollice  at  the  eoiiiniencenient  of  fiiK-raticin  from  palvano- 
eanl^ry  iiicisioii  into  llie  irrowth.  Tlio  man.  ajjcd  '22,  had  been  treated  t)y  a 
surjienti  fur  a  i)h'ediii;r  ".Mowth  in  his  nose  five  years  previously.  Sevetal  at- 
leiiil»ts  were  made  at  tliat  time  to  remove  it.  but  each  time  there  was  ex<f'ssive 
hfeniorrha<,'e.  folh)\ved  l)y  rapid  jxrowth  of  the  tumor.  A  section  «as  removed 
for  microseopieal  examination  and  it  was  pronouneed  sareonia.  Sul)seqiiently 
he  went  to  a  liospifal  in  one  of  the  \Mantie  v-^ities  to  have  it  removed.  This 
would  appeal-  to  have  been  successful'y  ac('om)ilisi."d.  for  it  did  not  recur  again 
until  about   a  year  Ix'fore  he  eamo  *.o  me  for  treatment. 

On  examination  I  f<nind  the  posterior  half  of  the  right  na-al  fo.isa  tilled 
with  a  grayish-red  growth.  In  front  of  it  was  a  wide  cavity  with  completi; 
ai)sence  of  inferior  turbinated  bone:  probably  removed  at  the  former  ojxTa- 
tion.  'Die  attachment  was  widely  sessile,  extending  over  the  upper  part  of 
septum,  vault  above,  and  middle  turbinated.  Posteriorly  it  pressed  the  palate 
downward,  the  septum  to  tlie  left,  and  the  Kustachian  tube  liaekward. 

As  it  was  impossible  to  snare  it,  owing  to  its  wide  attachment.  I  con- 
cluded to  try  successive  operations  with  the  galvai.  ^cautery.  Tlie  first  opera- 
tion was  at  the  lower  sept^il  attachment,  indsing  upward.  There  was  little 
bleeding.  Two  days  later  the  ojieration  was  rejicated  at  the  outer  margin. 
This  time  the  bleeding  was  severe,  and  I  inserted  kite-tailed  tampons  to  control 


FIBROMA. 


i;n 


it.  One  week  liiti-r  1  iiifiscd  the  I'Ciitral  iioitioii  bctwci'ii  tlic  two  fovincr  cuts. 
In  11  iVw  Ht'coiuls,  while  tlii'  instriiiticiit,  was  still  in  position,  aiti'iiiil  blood 
oonniicnicil  to  jt't  vij,'(!ioiisly  from  tlio  nose;  kite-tailed  tanijioiis  weic  resoited 
to  a<;ain.  witlmnt  avail.  Dr.  I'eeve  kindly  eanic  to  my  assistance  and  we 
jilugycd  the  nostril  from  liehind  with  l!ello((j's  cannula  (Kif.?.  ").">).  I'lie  patient 
was  in  a  eollapsed  condition,  and  was  confined  to  lied  for  seveial  days,  at  the 
♦■nd  of  which  time  1  removed  the  plnj.'-s  and  coiiimeiiccd  the  use  of  hipolar 
electrolysis.  The  needles  were  inserted  a  (piartcr  of  an  inch  ajiart  thron;^!!  tiie 
anterior  naris  into  the  growth.  This  was  repcatcil  at  several  sittings,  produc- 
ing ])allor  of  the  growth  and  slight  shrinkage.  Then  the  current  was  changeil, 
one  straight  lU'cdlc  iiciiig  inserted  tiirough  the  anterior  naris  into  the  growth 
anif  a  curved  neidle  passed  Ijcliind  the  palate  and  into  the  tumor  from  hehiiul. 
The  uniurc  in  each  case  was  from  tliree  to  five  minut<'s,  all  the  patient  could 
endure,  although  2U-per-cent.  solution  of  cocaine  had  licen  apjilicd. 

I  then  returned  to  the  use  of  the  galvanocautery-knife,  and  little  hy  little 
destroyed  the  whole  of  the  growth  witinnit  further  accident.  There  were  six- 
teen oi.ierations  ill  all.  covering  a  jjcriod  of  two  nmntlis.  One  half  the  o]icra- 
tions  were  through  the  anterior  naris;  the  other  half,  though  jierforined 
through  the  anterior  naris,  were  guiih'd  hy  light  retlectcd  from  the  post  riiinal 
mirror. 

Twice  over  microscopical  sections  were  made,  and  they  proved  the  growth 
to  be  a  fclose-grained  fibroma. 

This  is  now   four  years  after  the  operation,  and  there  has  been  no  return. 

It  is  l)tit  liircly  that  filiroiiia  of  the  nose  is  quite  pure  in  its  for- 
mation. I'rciiiiciitly  there  is  a  eoinhination  witli  iny.xoma,  sarcoma, 
or  angioiiia,  or  else  the  so-caTied  soft  iil)roina  of  Stoker  or  Victor 
Laiiii'e.  coniixised  of  vasciihir  |ia]iil]ary  growths  of  the  niiddK;  and 
inferior  tin  liiiiatt'(ls. 

I'rohalijy  uiic  of  thi'  iiio;-!  cliaracteristii^  cases  of  pure  (ibroina 
that  has  oeetirred  was  the  one  reported  hy  Cliark's  Knight.  It  was 
composed  of  dense  iiI)rons  tissne.  with  colh'clions  of  small,  rotind 
cells  of  inllammatory  origin  near  certain  points  of  its  surface,  and 
it  was  noted  hy  its  absence  of  vascularity.  It  was  pediiiiciilated  and 
its  removal  easily  accomplished  hy  cold-wire  snare.  Tiierc  was  no 
recnrrence. 


|!«t 

iM'ii 


m  ^1 


s 


vr 


,M. 


hh 


("IIArTKU  XXI. 

A I )  1-;  N  0^\  A  _;   A  N  (J  1 0.M  A. 

Ai»i:\(»M  A. 

Auknoma  of  tlic  iia.-iil  imssiincs  is  so  (■.xcccdiDnly  Viirc  jliiii  ajiy- 
tli'm^iT  iiini'i'  tliiin  iui  iillurion  to  it  will  not  lie  iicco^iuv  iicii'.  'I'iio 
iiiinie  indiciiti's  that  it  is  a  growth  of  Lrlamlular  cliaracte'i';  ami,  as 
tlio  ji'lnnds  within  the  nasal  ("'avity  arc  few  in  nnnihci'  and  only  limited 
in  action,  it  can  readily  lie  seen  that  tnniors  of  a  jilaiidular  nature  in 
ihi>  reuidii  must  of  a  nece.-sity  lie  infi'c((uent. 

Still,  thill  they  do  occur  is  verified  hy  several  instances  that 
have  heeii  rceoi'ded:  and  a>  or.e  rt'jiortcd  hy  (ios>elin  irivcs  th(>  his- 
tory, pathology,  and  treatment  of  the  case,  1  will  repeat  it  as  de- 
scribed liy  him:^ — 

"A  man,  a^^ed  I.'),  presented  with  the  following  history:  I'^arly 
in  ISoT  he  developed  iiasal  stenosis,  for  which  ho  sought  iclici;  at 
the  hospital,  early  in  the  April  I'ollowinir.  when  a  numbci'  of  polypi 
weie  removed.  A  scecmd  operation  of  tiie  same  character  was  done 
in  October.  In  Februai'y,  ISoS.  he  was  seen  hy  Gosselin,  who  found 
the  light  nasal  jiassage  comph'tely  closed  by  a  tumor  which  presented 
at  the  nostril  and  also  projected  into  the  })harynx.  It  was  of  iiim 
( onsistency  and  grayish  in  colur,  the  surface  being  soft  and  pul- 
laceous.  Tt  was  attached  in  front  and  above.  An  operation  being 
decided  upon,  access  to  the  cavity  was  obtained  by  external  incision, 
and  the  giowih  extracted  by  means  of  forcc[is  and  manipulation. 
The  o])eration  was  attended  by  but  slight  hioniorriiage.  ]\Iicroscop- 
ical  examination  showed  the  growth  to  be  composed  of  'abundant 
epitlielial  cells  with  glandular  ntl-dc-saci^,'  on  wliich  the  diagnosis 
of  a  glandular  tumor  was  based.  The  operation  was  successful  and 
the  oaticnt  left  the  ]ios])ital  apjiarently  cured." 


AxcroMA. 

AVhen  we  consider  the  exceedingly  vascular  nature  of  the  nasal 
mucosa,  we  would  naturally  be  of  the  opinion  that  it  would  be  prone 
to  the  development  of  angiomatous  tumors.    Still,  very  few  cases  have 


.\MilOMA. 


VM 


been  vceordcd,  proljubly  not  iiioru  than  20  in  all.  Aindiiu'  the  most 
recent  is  the  one  reported  to  the  Larynirological  Society  of  liondon 
in  March,  181)(),  by  St.  Clair  Thonl^^oll.  Jl  was  removed  I'rom  the 
riglit  middle  meatus  of  a  man  aged  29.  The  growth  was  the  size  of 
a  liazel-nut,  irregidarly  ovoid,  and  lobr'ated.  It  was  attached  by  a 
hluisli  ])edicle  to  the  right  cartilaginous  '.ptum  and  removed  by  snare. 
'L'here  was  free;  lueniorrliage,  checked  by  the  galvanocautery.  Ueciir- 
rence  took  ])lace.  This  was  also  reieovcd.  .Mieroscoj)ical  sections 
were  made,  proving  the  tumor  to  ho  ait  angioma. 

Pathologically  these  section,-  were  almn>i  completely  surrounded 
by  ncu'mal  columnar  epillielium.  in  some  parts  innnediately  beneath 
the  e])ithelium  thei'c  was  loose  connective  atul  myxomatous  tissue; 
while  in  other  parts  the  epitlielinm  lay  directly  on  tlu'  new  growth, 
'i'his  was  compose<l  almost  cnlii'cly  ol'  hlood-vox'ls  of  very  dilTcrcnt 
sizes  whose  walls  were  formed  of  cells,  and  did  not  contain  either  elastic 
or  mu.-cniar  tissue,  '['he  stroma  between  the  vessels  consi.-ted  of  loose 
fibrous  tissue,  willi  oval  and  spindle  cell-,  which  weic  of  uniform  char- 
acter thronghonl.  and  arranged  around  the  \<'ssels.  among  which  was  a 
good  deal  of  e\t  I'avasated  l)io()(l. 

This  account  of  the  histological  conditions  of  Thomson's  case 
does  not  dilfcr  materially  from  the  jtathology  of  the  <lisease  described 
by  Ijosworth  years  ago. 

The  etiologv  is  doubtful,  it  being  dillicnll  to  assign  a  definite 
cause,  cithei'  active  or  ])redisposing.  iioswoi'th  suggests  that  it  nuiy 
arise  from  disturbed  nutrition  of  the  vascular  walls.  It  occurs  during 
all  ages  of  life. 

The  symptoms  are  similar  to  those  attending  iiasal  fibroma,  ex- 
ce])t  that  the  softer  character  of  the  growth  will  ])revent  nasal  de- 
formity by  pressure.  Angioma  diifers  also  from  lUiroma  in  not  being 
dangerous  to  life  and  in  being  more  readily  anu'nablc  (o  treatnu'iil. 

Treatment. — About  the  only  treatment  recommended  is  removal 
either  by  the  steel  wire  or  galvanocaiitery-snare.  Tlu;  former  is  con- 
sidered the  l)est,  as  by  slowly  tightening  the  wire  hannorrhage  may 
be  avoided,  darvis's  snare,  with  its  nut-screw,  is  believed  to  be  the 
best  adapted  to  the  Irealmcut  of  these  cases,  placing  the  wire  as  high 
as  ])ossible  upon  the  jiedicle. 


11  HI 


i  m 


4r' 


ii! 


i^'i 


CIlAlTKIf  \.\ll. 


CVSroMA  Ol'  TIIK  NOSK. 


|f'«; 


Dki.avan  ro])Oi'U'il  in  IS!*,")  iIhto  cases  of  this  soiiiowhat  lari; 
atl't'itinii.  ^riicy  \VL>rc  all  lasi'.s  which  had  hecn  i'or  yt-'iti'^  all'i'ctcd  with 
nasal  polypi  and  in  which,  after  rcpcatcil  opi'ralioiis  for  their  rc- 
iMiival.  cystoma  had  eventually  di'veloped.  in  one  case  the  u'lMwth 
hiinif  ont  of. the  nasal  fossa  into  the  posl-pharyniical  space,  it  was 
rdund,  and  ahoiit  an  inch  in  diameter,  ami  was  renioved  hy  Jarvis's 
snare.  In  llie  other  two  cases  all  elforis  to  remove  them  were  iin- 
axailinji  until  the  growtiis  had  heeii  punctured.  'Then  a  ];\vgv  amount 
of  tluid  drained  away  and,  the  walls  collapsing,  they  were  removed 
hy  snare  or  poIypu.s-l"orcc])s.  Microscopical  examination  of  the  rem- 
nants, niade  in  each  case  hy  Dr.  llodenpyl,  jn'oved  them  to  bo  com- 
posed of  columnar  and  ciliated  epithelium,  glandular  matter.  fil»rin, 
and  cell  ilclriliis,  diagnosing  each  case  as  loose  iihroma.  The  fact 
that  eacli  of  them  contained  ciliated  epithelium  would  prove  their 
origin   from  the  middle  or  lower  tui'l)inalcds. 

The  cases  of  Johnson,  Watson,  and  J^'U'ei'ts.  as  reported  hy  I'ms- 
worth,  were  also  of  iniddle-turhinal  origin  (Fig.  01). 

Urown  Kelly  {Joiinuil  of  Jjari/nj/oltuju,  lijiinolotjii,  ainl  Oliihujij, 
June,  ISihs)  gives  a  report  of  an  entirely  different  series  of  cas^s  of 
cystoma  of  the  nose.  The  situation  of  developnu'iit  is  the  lloor  of 
tho  fossa;  and  as  no  full  account  has  heretofore  been  ])ublished, 
together  with  the  history  of  his  cases,  ho  gives  a  sketch  of  tlie  diseasi-. 

Jt  always  occurs  in  females.  .\t  any  rate,  the  twelve  cases,  up  to 
the  ]ireient  lime  !'ep(>rte(l.  have  all  appeared  in  wnnien.  the  ages 
being  l)elween  nineteiii  and  lifty-eight  years.  The  site  of  formation, 
likewise,  is  always  the  same,  ht'ing  the  outer  lloor  of  the  nostril, 
anterior  to  the  inferior  turbinated  body,  and  just  behind  the  union 
of  the  skin  w  ith  the  nasal  mucous  meml)rane.  The  appearaiu^'s  within 
the  nose  vary  only  in  dogre(>.  When  the  cyst  is  small,  it  forms  a  gray- 
ish hemispherical  eminence,  about  the  middle  or  outer  half  of  the 
floor.  As  the  sac  enlarges,  it  extends  t)ackward,  aiul  also  downward 
into  the  incisor  fossa,  hut  verv  rarelv  toward  the  septum. 
(134) 


CYSTOMA    OF   TJIK    NOSE. 


135 


would   ' 


mm  tho^i^ringivo-lal.iiil  fold 
two  of  the  cases  report od 

- -'- '".■«"■ '  M;::;r:r;::,',,.;;;':;;2 


^£:L«';K-*:™-:s.i:;~i:;"r,K;;i 


i!   U 


' 

# 

f 

k'- 

mu 

< 

Im 

•«■■» 


¥ 


CHAPTER  XX 111. 


ClION  IJRO.M A ;   OSTEOMA. 


Mi 


in  : 


C'lIONDUOMA. 

Most  of  tlio  cases  ot  ciirtilaginoiis  onlargcincnt  within  the  nose 
that  C'onu;  imdiT  observation  are  merely  hypertrophies  of  tiie  cartilag- 
inniis  septum,  and  cannot  be  placed  under  this  head.  The  term 
"('hoiidroma"'  is  confined  to  those  cases  of  round  nodulated  tumor 
occasiojially  met  witli  wJiicli  niacroscopically  resemble  fibroma,  but 
which  on  closer  examination  are  found  to  consist  of  cartilage.  They 
are  usually  found  at  the  anterior,  inferior  angle  of  the  cartilaginous 
septum. 

The  etiology  of  these  growths  is  still  unknown.  The  period  of 
their  dcvelojinient  is  during  the  adolescent  years  of  life.  The  symj)- 
toms  are  sim.ilar  to  those  produced  l)y  benign  neoplasms.  They  differ, 
however,  from  fibroma  and  angioma  hy  being  unattended  by  ha;mor- 
rhage  and  by  their  yellowish  color.  To  touch  they  are  liard  and 
cartilaginous,  hut  the  pressure  of  a  needle  will  distinguish  them  from 
the  still  greater  hardness  of  osteoma.  In  structure  they  are  com- 
posed of  hyaline  cartilage,  combined  with  white  librous  and  yellow 
elastic  tissue. 

Simple  surgical  treatment  is  required,  the  object  being  removal 
of  the  growth.  U'hethcr  this  is  done  by  snare,  scissors,  curette,  gouge, 
or  knife  is  immaterial,  so  long  as  the  tumor  is  completely  excised. 
There  appears  after  successful  operation  to  be  no  tendency  to  return. 

Osteoma. 

Osteoma  requires  to  be  distinguished  from  exostosis,  as  the  latter 
term  ajjplies  to  bony  outgrowths  of  the  septum,  at  the  sutural  junct- 
ure of  the  vomer  with  the  perpendicular  plate  of  the  ethmoid,  or 
the  palate,  or  maxillary  bones,  wliile  the  former  is  restricted  to  osseous 
neoplasms,  having  their  origin  independent  of  sutura^  union.  They 
are  usually  located  in  the  upper  portion  of  the  nose,  having  their 
origin  in  the  bones  of  one  or  other  of  the  accessory  sinuses. 
(13fi) 


( 


I 


OSTEOMA. 


i;57 


Pathology. —  In  soiin'  t'ascs  tlio  osteoma  is  D.adc  up  oiilirely  of 
liani,  c'uiiipat't  tissue.  In  otlitrs  tiie  body  of  tlio  hone  is  cancellous 
ami  covered  with  a  close  and  compact  layer.  In  Adenot's  case  the 
tumor  was  an  osteogenic  exostosis,  with  a  ehondromatous  envelojje. 
In  Coakley's  it  was  exceedingly  hard.  s[iringing  from  the  inferior 
turhiiiated,  and  of  tertiary  syphilitic  formation. 

Etiology. — The  etiology  is  unknown.  rossil)ly  it  may  arise  from 
some  constitutional  dyscrasia.  The  period  of  it;',  greatest  freciuency 
is  eaily  life.     The  niaj(nity  of  cases  are  said  to  occur  in  males. 

Symptomatology.— Mxterna I  defoiinity  is  one  of  the  earliest 
synipt(iM)s.  This  is  owing  to  the  situatiim  nf  the  growth,  hcing  in  the 
upper  part  of  the  nose.  ll(>nce,  stenosis,  one  of  the  earliest  symptoms 
produced  hy  the  majority  of  benign  nasal  neoplasms,  may  be  late  in 
appearing.  Pain  is  likely  to  occur,  owing  to  jjressure  upon  the  nerve- 
iiliiments.  In  Adenot's  case,  epileptic  seizures,  produeeil  by  rcllex 
aelion  of  tumor,  wcr(>  relieved,  after  veitieal  osteotomy  had  been  per- 
formed, l'!pistaxis  ami  nasal  di.-charge  are  neither  of  them  likely 
to  be  troublesonu'.  The  jioinl  (d'  origin  is  fret|uently  in  the  neigh- 
borhood of  the  ethmoid  (H'lls,  and  may  be  fr(Mu  little  islands  of  car- 
tilage or  l)one  in  the  mucous  membrane. 

Osteonuita  are  usually  irregularly  lobulated  an<1  covered  with 
mucous  membrane.  When  the  growth  has  s|)aee  enough  to  develop 
itself  v.ithout  infringing  upon  surroniuling  bony  structures,  it  will 
remain  free  and  rounded.  It  is  when  its  development  becomes  im- 
peded by  osseous  resistance  that  it  becomes  lobulated  or  tlattened. 
If  from  any  cause  its  attachment  1)ecoines  fractured,  it  may  remain 
within  the  nasal  cavity  as  a  foreign  body. 

Treatment. — Osteomala  difl'er  from  other  nasal  neoplasms  in  the 
fact  that  they  usually  rc(piire  external  operations  to  accomplish  their 
removal.  This  is  owing  to  the  density  and  size  of  the  growth  and 
the  dillicnlty  in  reaching  the  site  of  attachnu>nt.  The  surgical  oper- 
ation required  to  reach  the  growth  is  sometimes  more  dillicult  than 
the  excision  itself.  This  must  be  conducted  upon  ordinary  surgical 
]irinciples.  When  the  tumor  is  reached,  the  chisel,  saw,  or  forceps, 
may  readily  separate  the  neck  from  its  attachment,  Ifa'morrhage, 
which  is  sometimes  severe,  requires  to  be  guarded  against. 


li! 


I 


ll 


(  IIAI''1'K1{  X.\l\. 


SAUCOMA. 


FoiM  TNA'iKi.Y  this  iiiiilijii:.'nt  cUsfii.-o  nirt'lv  occiir-s  williiii  thf 
iiiisnl  I'ossn.  Altli(Uifj;li  tlie  iiinjorily  of  enscs  occur  in  niatiiro  lil'o,  the 
aviTii^e  iij;e  of  piiticiils  iilllictod  with  it  is  less  tluui  in  carcinoma, 
while  tho  yoiiii^'cr  the  patient,  the  greater  tlie  nuiliffniincy  and  the 
quicker  the  fatal  result.  The  usual  site  is  the  septum,  but  it  may 
arise  from  the  turi)iiiate(lp  or  any  other  portion  of  the  nasal  cavity. 

Pathology. — Tlie  pathological  hi.3tory  of  sarcoma  of  the  nose  does 
not  diil'er  from  that  of  otlier  regions  of  tho  body.  It  originates  from 
tile  meshes  of  connective  tissue  and  is  fdled  with  round,  ovoid,  and 
fusiform  cells,  the  round  often  prevailing.  Myeloid  and  large  granu- 
lar cells  are  often  jirescnt  in  large  numbers.  When  the  granular 
structures  of  the  mucous  membrane  have  undergone  proliferation  in 
connection  with  the  development  of  round-  or  spindle-  celled  elements, 
adenosarcoma  may  result.  In  other  instances,  proliferation  of  the 
stellate  mucous  cells,  together  with  the  sarcomatous  elements,  would 
indicate  myxosarcoma;  while  in  cases  where  the  ordinary  blood- 
vessels are  lost,  and  vascular  spaces  are  foiind  instead,  in  connection 
with  the  sarcomatous  develojmient,  angiosarcoma  is  the  result. 

Etiology. — The  history  of  the  forty-one  cases  collected  by  Bos- 
worth,  and  another  dozen  that  have  been  recorded  since  then,  throw 
little  light  upon  the  subject.  Some  were  preceded  by  nasal  polypi, 
which  might  bear  a  causative  relation  to  the  development  of  the 
malignant  disease;  but  a  very  large  number  arose  de  novo,  and  with- 
out assignable  cause.  Some  writers  believe  that  surgical  traumatism, 
in  the  way  of  galvanocautery  and  forceps  operations,  is,  in  some  in- 
stances, a  cause.  As  an  objection  to  this  idea,  it  may  be  argued  that 
a  large  number  of  the  severest  cases  of  sarcoma  occur  in  the  earlier 
years  of  life,  when  prior  nasal  operations  have  not  been  thought  of. 
Personally  I  have  never  seen  a  case  of  malignant  disease  of  any  kind 
which  could  in  any  way  be  traced  back  to  operative  treatment. 

Symptomatology. — The  first  and  most  prominent  symptom  is  ob- 
(138) 


I  • 


1 1 


SARCOMA. 


1311 


striu'tioii  to  M;i.-.il  liroathinj:.  This  is  soon  I'ollowod  or  aicnmjiiiniod 
l)_v  ii  I'd'tid  mucous  ilis(liar<,^'.  Tlir  color  is  often  ^Tocnisli  anil  luciiior- 
rlia|,'e  I'roqiicntly  occurs.  This  ()(h)r  arises  in  part  from  (h'coiiiposcd 
rctainod  secretions,  i'ain,  ahhongh  not  necessarily  severe,  is  of  fri'- 
iiueiit  occurrence  and  is  due  to  pressnrc.  When  h)eated  in  the  an- 
terior region  of  the  nose,  there  may  ho  great  deformity.  \Vh(  n  in 
tile  posterior,  deafness  and  dysphagia  may  result.  W  Inn  in  the  upper 
and  middle  tiirliinal  region,  destruction  of  ihe  crihrifcu'ni  plate  id' 
the  t'thnioid  and  extension  id'  the  disease  to  the  luaiii  may  had  to  a 
fatal  issue. 

Sarcomata  Idecd  ea.-ily  when  touched  with  a  prohe.  'I'licv  have 
no  ic~iliency,  and  li.-ivc  ;i  reddish  color,  freijucntly  a"UminL:'  a  hluish 
or  violet  tinge.  Thev  occur  sinulv  and  may  ho  either  iieduuculated 
or  have  a  liroad  or  sessile  hasc. 

Diagnosis.  —The  malignancy  of  the  growth  can  scarcely  I'scapi 
recognition  after  careful  rhinoscopie  e.xannnation.  The  soft  ])ulla- 
ceons  tissues,  with  reddish-gray  surfaces,  foul  odor,  and  olTensive  di.-- 
oliargc  will,  in  many  instances,  at  once  ,-tamp  the  nature  of  tlu'  dis- 
ease. l)ut,  wiien  occurring  in  mature  years,  nothing  hut  microscop- 
ical examination  will  ])ositively  distinguish  it  from  carcinoma. 

Prognosis. — It  is  a  hopeless  disease  save  for  the  relief  that  may 
he  ohtained  from  operative  treatment.  Wlien  taken  early  and  thor- 
oughly removed  liy  operati'Ui,  there  is  a  fair  prospect  of  recovi  ly. 
One-half  the  cases  reported  up  to  the  present  time  are  said  to  have 
been  cured.  ^IMiis  statement  must  he  accepted  with  much  reservation, 
as  many  of  the  reports  were  ohtained  hut  a  short  time  after  operation 
and  l)efore  there  could  well  he  a  recurrence  of  the  disease. 

Treatment. — Complete  extirpation  when  the  disease  is  not  too 
far  advanced  for  operation  is  the  only  correct  method  of  treatment. 
"Without  there  is  good  prospect  of  this  l)eing  accomplished,  it  should 
not  he  attempted  at  all.  With  regard  to  the  nature  of  the  operation. 
each  case  must  he  a  rule  for  itself. 

When  the  removal  can  he  made  through  the  anterior  nares,  with- 
out facial  operation,  it  is  much  the  better  ])lan  to  follow,  taking  the 
neoplasm  away  by  smire,  curette,  spoon,  cautery,  etc.,  or  all  cond)ined. 
as  tlie  case  may  require,  always  guarding  against  the  possil)ility  of 
excessive  Invmorrluige.  This  method  can  only  be  available  in  the 
very  earliest  stages  of  the  disease,  the  parts  being  antcsthetized  by  a 
strong  solution  of  cocaine. 

In  other  instances,  however,  primary  surgical  operations  tlirough 


1     'ii 


JV  i 


I',;  " 


140 


DISEASES   OF    JlIE    NASAL    PASSAGES. 


tlic  nose  or  soft  palate  will  be  reqiiiietl  before  the  base  of  the  growth 
can  be  reachod.  Having  eradicated  the  tumor,  the  parts  are  replaced 
by  regular  surgical  methods  and  the  internal  wound  treated  as  tlio 
conditions  of  the  parts  may  rcipiire. 


liil 


ClIAPTKK  XXV. 


CARCINOMA. 


IvAKE  as  is  sarcoma  wilhiii  the  iiasal  cavity,  .^till  more  rare  is  tlie 
more  malignant  disease  eareinoma.  Tlie  average  age  of  persons 
afllicted  witli  it  is  also  somewliat  greater,  althoiigli,  as  in  sarcoma,  tlie 
period  oi'  cliildliood  is  not  entirely  exempt.  The  thirty  cases  carefully 
collected  liy  J5os\vortli  were  all  of  primary  origin,  and  the  same  may 
1)0  said  of  the  cases  of  llindc.  'Mas  Tliorner,  llaton,  Dreyfuss,  Fliitan, 
Domoe,  Sync,  lloj)kins.  and  Lennox  Urowne  which  have  occurred 
.siiu'c  tlic  issue  of  iJosworth's  woi'k.  That  is  to  say,  in  each  of  these 
cases  the  epithelioma  made  its  appearance  lirst  within  the  nasal  cavity. 

In  all  these  cases  tlie  oidy  elaboration  of  the  carcinoma  was  by 
extension,  and  not  hy  formation  of  new  foci  in  distant  regions.  As 
secondary  carcinoma  of  tlic  n«ise,  I  have  so  far  not  been  able  to  find 
a  case  on  record,  although  extension  to  the  nose  from  tlie  neighboring 
organs  might  possibly  occur. 

Fc*;hology. — As  in  sarcoma,  the  path(ih)gy  of  carcinoma  is  the 
same  wherever  found.  When  near  the  cutaneous  surface,  the  cancer 
Tiiay  be  ;;  squamous  epithelioma  (\'erncuil).  Dee]ier  within  the  cavity 
the  a(hiio-('pilhelial  type  may  he  devchipcd.  as  in  the  i-ase  recently 
reported  by  Ma.x  Thorncr.  'J'liroughout  the  growth  an  enormous 
mass  of  tubuli  or  alveoli  will  be  found  surroundt'd  by  connective  and 
epithelial  tissue  and  filled  with  colloid  substance. 

Etiology. — Hereditary  inlluence  is  probaldy  the  most  potent 
jiriinary  cause  in  the  develojimcnt  of  cancer,  (jiraniing  this,  we  know 
that  physical  injury  is  frequently  the  exciting  cause  for  its  develop- 
ment in  other  jiarls  of  the  body.  Possibly  the  reason  of  its  extreme 
rarity  in  the  nose  is  the  infrecjuency  of  s>vcre  traumatism  in  that 
region.  It  is  a  disease  which  rarely  occurs  until  after  middle  life. 
The  possibility,  h  wever,  (d"  the  development  of  malignant  disease 
from  eiiner  myxoma  or  iibroma  of  the  nose  is  now  an  acknowledged 
fact. 

Symptomatology. — The  .^ymjitoms  are  almost  identical  with 
those  produced  by  sarcoma  of  the  nasal  passages.  Tiie  submaxillary 
glands  are   more   likely  to  be   involved,   the   cachexia   t©   be   more 

(111) 


immmmmtm 


U2 


niSKASKS    OF    THE    NASAL    I'ASSACSKS. 


!■ 


M 


marked,  nnd  the  progress  of  the  disease  more  rapid,  wliile  the  average 
ago  of  the  ]iationt  is  greater.  But  the  stenosis,  the  oltcnsivo  and  foul 
discharges,  tlio  deforniity,  and  the  internal  appearance  of  tlie  growth 
arc  very  mneh  alike  in  hoth  diseases. 

Diagnosis. — Tlic  diagnosis  must  depend  materially  on  microscop- 
ical examination,  the  resemblance  to  sarcoma  being  so  great  that  the 
distinctive  cancer-cells  would  need  to  be  discovered  to  insure  a  posi- 
tive opinion.  From  tuberculosis  and  syphilis  the  clinical  history 
should  be  suificiently  jiositive  to  make  the  diagnosis  certain,  par- 
ticularly with  microscopical  aid. 

Prognosis. — The  prognosis  is  the  worst  that  can  l)e  ex])ected, 
except  in  exceedingly  rare  cases  where  the  disease  has  been  recognized 
and  promptly  removed  upoii  its  earliest  manifestations.  Even  in 
these  cases  sj)eedy  recurrence  is  more  than  a  possibility. 

Treatment. — The  majority  of  cases  do  not  come  under  observa- 
tion until  after  the  disease  has  become  thoroughly  seated  and  the 
deep-lying  tissues  involved.  In  such  cases  operation  would  be  useless, 
and  would  only  induce  more  rapid  development.  All  that  could  be 
done  reasonably  would  be  in  the  way  of  soothing  antiseptic  applica- 
tions, such  as  cocaine,  aristol,  iodoform,  iodol,  etc.,  together  with 
systemic  support. 

In  early  cases,  when  there  is  freedom  from  glandular  enlarge- 
ment and  a  fair  prospect  of  complete  cradlcaiion,  it  would  be  the  duty 
of  the  surgeon  to  extir{)ate  at  once,  and  by  the  most  available  means, 
as  already  described  in  dealing  with  sarcoma,  the  main  features  of 
the  operation  being  to  avoid  undue  injury  to  surrounding  parts,  bear- 
ing in  mind  the  possible  evils  of  traumatism  upon  already-weakened 
tissues.  A  large  number  of  these  cases  occur  in  the  ethmoid  region, 
and  one  can  see  how  hopeless  radical  o])eral:ion  wotdd  be  even  in 
the  most  initiatory  stages.  In  very  few  instances  has  operation  been 
successful  even  in  giving  temporary  relief,  while  in  not  a  few  it  has 
hastened  the  final  issue. 


CHAl'TEll  XX Vi. 


TUBERCULOSIS. 


As  AN  indioatiou  of  the  rarity  witli  which  tuhorculosi.s  attacks 
tlic  nasal  passaizes,  Willigk,  out  of  42G  autopsies  upon  tlie  bodies  of 
persons  who  had  died  of  tuhoreuh)sis,  found  only  1  case  in  which  the 
disease  had  alfccted  the  iu)sc:  and  Weichsel!)aum,  out  of  1«!1  similar 
autopsies,  found  only  '2.  On  the  other  hand,  rare  as  iho  disease  is  in 
this  region,  J^eidel  reported  2  cases  in  which  primary  tuberculosis  of 
the  septum  existi'd  lor  years,  without  tlie  liinus  being  in  any  way 
alfected  by  the  disease;  and  William  J I  ill  in  ]8!)(i  reported  1  of 
tuberculosis  of  the  inferior  Uirbinated  in  whicli  disease  of  the  lung 
was  so  slight  fhat  he  mistook  the  nasal  disease  to  be  nuilignant,  and 
performed  turbiiu'ctomy.  The  patient  did  well,  although  subse(]ueMt 
microscopical  examination  proved  it  to  ijc  a  case  of  tuberculosis. 
Symonds,  Watson,  Williams,  and  riaeh  have  all  reported  cases  of 
primary  septal  origin. 

Pathology. — The  exhaustive  investigations  of  recent  patholo- 
gists, particularly  of  such  men  as  St.  Clair  Thomson  and  Hewlett, 
have  thrown  new  light  upon  the  subject  of  nasal  pathology.  These 
gentlemen  jiroved  that  about  500  litres  of  air,  containing,  on  the 
average,  inoo  bacteria,  are  inspired  every  hour  by  each  person.  Thir- 
teen healthy  individuals  were  examined.  As  the  vestibule  of  the  nose 
contains  vibrissio  and  is  line(l  by  membiane,  partly  integumentary 
and  partly  mucous,  they  made  one  series  of  cultures  and  cover-glass 
preparations  from  the  vestibule  and  another  series  taken  from  the 
mucous  nuunbrane  deeper  within  the  fossa.  The  result  was  that,  while 
in  the  first  series  they  fouiul  a  large  uund)er  of  micro-organisms,  in 
the  second  they  found  very  fow,  80  per  cent,  of  them  Ijcing  sterile, 
having  no  micro-oi'ganisms  at  all.  The  natural  conclusion  is  that 
the  comparative  immunity  of  the  nose  from  such  diseases  as  tuber- 
culosis, cancer,  sarcoma,  syphilis,  etc.,  is  due  in  some  measure  to  the 
bactericidal  properties  possessed  liy  the  jihagocytes  of  the  nasal 
mucosa. 

There  arc  two  forms  in  which  tuberculosis  of  the  mucous  mem- 
brane of  the  nose  may  ]iresent  themselves.     In  the  one  ulceration 

(14.3) 


■MvM 
L'  IF 

I'i  ^i 


]<m 

H[r; 

\  !•! 

'■ !"  '  ^ 

;tii- 

^1 

i  i 

III 

lj 

■  V 

"I  1 

14-i 


DISEASES    OF    THE    NASAL    PASSAOKS. 


i1 


may  take  ])laco,  either  on  tlie  septum  or  on  the  floor  of  the  inferior 
meatus.  In  tiie  otlier,  hyperplasia,  witli  a  sessile  hase,  may  appear 
upon  the  septum,  the  inferior  turbinated,  or  the  outer  wall.  Ulcer- 
ation fdllows,  surrounded  by  pale  granulations.  There  is  usually 
more  or  less  round-celled  infiltration,  together  with  nucleated  epi- 
thelial cells.     Tubercle  bacilli  are  frequently  few  in  number. 

Etiology. — Tlie  disease  usually  occurs  as  a  secondary  deposit, 
following  j)ulnionary  tuberculosis.  In  some  cases  the  method  of  at- 
tack is  said  to  be  by  autoinfection,  from  contact  of  the  sputum  during 
coughing  with  an  excoriated  septum.  In  others  it  occurs  through 
tlie  lym])hatics.  One  case  is  reported  by  Chiari  to  have  been  caused 
])V  infection  from  the  antrum  of  Ilighmore.  In  some  cases  the  germs 
must  have  come  from  without,  dust,  laden  with  bacilli,  being  de- 
j)osited  upon  abraded  mucous  membrane  near  the  anterior  nares. 

Symptomatology. — When  hyperplasia  has  taken  place,  it  is  of  a 
grayish-red  color,  soft  and  protruding,  bleeding  easily,  and  of  irregu- 
lar outline.  It  is  often  covered  with  mucus  or  crusts,  with  a  tend- 
ency to  ulceration.  When  ulceration  takes  place,  crust-formation  is 
likely  to  be  tr..ublesome.  Stenosis  is  (?ften  present,  but  there  is  no 
pain.  The  usual  discharge  is  that  of  grayish  mucus,  the  amount 
depending  on  the  severity  of  the  ulceration. 

Diagnosis. — Tuberculous  ulcers  wherever  found  always  present 
similar  appearances.  The  color  is  usually  whitish  gray.  There  is 
little  loss  of  tissue,  the  centre  being  only  slightly  depressed.  The 
border  is  irregular  in  outline.  There  is  never  any  areola  round  the 
ulcer,  and  the  bluish-red  tinge  gradually  blends  imperceptibly  with 
the  surrounding  mucosa.  The  irregular  crusting  and  bleeding  of  the 
nose  are  produced  by  the  drying  and  irritating  effects  of  respiration. 
Tlie  neoplastic  form  of  tubercular  disease,  usually  found  in  the  in- 
ferior turljinated,  presents  an  appearance  of  little,  grayish-red  warts, 
and  must  be  distinguished  from  papilloma  by  being  smaller,  flatter, 
and  softer.  ^Microscopical  examination  will  usually  discover  tubercle 
bacilli,  though  in  small  numbers. 

Prognosis. — In  a  large  majority  of  cases  this  is  purely  a  second- 
ary matter,  depending  upon  the  progress  of  the  primary  pulmonary 
lesion.  It  is  usually  slow  of  development,  and  may  continue  for  years 
without  serious  results,  the  comparative  fatality  of  pulmonary,  laryn- 
geal, and  ])haryngeal  tuberculosis  not  applying  to  the  protected  cham- 
bers of  the  nose.  The  local  lesion  can  frequently  be  readily  removed, 
but  is  apt  to  return. 


TUBERCULOSIS. 


145 


aiipporting  measures  arc  also  raiuiml      'l'l,„  „!        ,      ,,, 
^=..pplyas)arKcnnamo,„,t„f„,Uri„ent    „    ,'         ,  ,'°"'"'  '"  '° 

forees  .-„„UI  l.nve  power        a^t^^.^  '1™  "^ 

iron,  and  sh,el,„:„e'are  .1,  us  ,■  ,"  i  Zvf:!^  'TT'i 
creasote  is  the  bc«t  fm-  ifc  e,-  f  •  !  ^  "-'"''''■ '  °^  '»'•'  carbonate  of 
tains  90  per  o  of  c4  sot  '"l'  T'  "'^'^^-■1-*-  ^^-ts.  It  eon- 
irritant,    an  b     ta  1  Iv  tal    1    "t>  '        "f  ''"'""^^  '''"'"''''''  '^'^  -- 

The  dose  is  1  toT    "'n!    ^      ■^'"    J"""'  ^'''"-^  ^'1'  ''""^  ^'^  «'^«"^'J^^'^- 

takenread  y   n    Jaror    :"    r  ""./'''•^^V''""  ^  ^^•^^-     ^^  -"  '- 
of  the  lattei  codbver-o,l,  „,  doses  of  10  or  15  grammes 


i.'i 


i 


m 


CJlAFTKll  XXVII. 


LUPUS;  GLANDERS. 


n 


Lui'us. 

Sometimes,  tliougli  rarely,  lupus  raay  occur  primarily  within 
the  iia.«al  l'os?a;  but  u.sually  the  cxtornal  nose  or  the  palate  is  affectccl 
first,  and  the  disease  extends  backward  or  forward  into  the  nasal 
cavity. 

Pathology. — Tbe  essential  pathological  change  in  this  disease  is 
the  deposit  of  round  cells  of  granulation-tissue  in  the  meshes  of  the 
mucous  membrane.  This  deposit,  or  infiltration,  is  gathered  in  little 
nuisses  or  nodules,  and  seems  to  follow,  in  a  measure,  the  course  of 
the  blood-vessels.  In  addilion  to  the  characteristic  round  corpuscles 
of  lupus  giant  corpuscles  also  occur.  As  tbe  nodules  rise  above  the 
surface  they  ulcerate;  but  the  nodular  reproduction  beneath  is  more 
rapid  than  the  siirface-desiiuamalinn;  consequently,  unless  the  dis- 
ease is  cheeked  by  medical  or  surgical  treatment,  the  proliferation 
of  the  neoplasm  is  in  excess,  and  the  nasal  passages  become  blocked 
by  the  development  of  the  disease.  Schiiller  has  found  irregular 
chains  nf  micrococci  among  the  granular  cells  and  extending  into 
the  surrounding  connective  tissue.  Neisse  was  the  first  to  demon- 
strate the  presence  of  tubercle  bacilli;  and.  as  more  recent  investi- 
gations have  frequently  discovered  their  presence,  the  theory  that 
lupus  is  a  species  of  tuberculosis  has  been  established. 

Etiology. — There  is  no  doubt  that  tlie  disease  arises  from  the 
deposit  of  a  specific  virus  which  produces  changes  of  an  inflammatory 
and  ulcerative  character  in  the  mcmljrane  affected,  and  that  a  stru- 
mous diathesis  is  a  prominent  factor  in  preparing  the  soil  for  the 
germ.  The  majority  of  cases  occur  in  the  early  years  of  maturity, 
but  quite  a  nundjcr  even  in  youth.  One  is  reported  at  the  age  of 
six  months,  while  Eeed.  Shurly,  and  Tresilian  record  cases  at  the 
fourteenth  year.  !Most  nasal  cases  attack  the  cutaneous  surface  first, 
and  the  mucous  membrane  afterward. 

Symptomatology. — A  certain  amount  of  nasal  stenosis  is  always 
present.  After  idceration  brownish  or  greenish-brown  crusts  form, 
accompanied  by  sanious  discharges  from  beneath  their  edges.  On 
(14(1) 


LUPUS. 


117 


lifting  tlio  crusts,  Ijlood  will  oxiule  from  the  central  parts  nf  IJio 
nodules.  Odor  is  not  marked,  but.  when  it  does  not  occur  from  reten- 
tion of  the  scabs,  it  is  of  a  musty  ciiaracter.  Pain  is  not  a  ])romi- 
nent  symptom,  nor  is  the  physical  system  materially  atfected. 

Diagnosis. — The  peculiar  reildish,  nodulatid  appearance  of  the 
external  m)se,  with  the  greenish-brown  crusts  and  eharacteristic  dis- 
charge, should  remove  all  ditliciilty  in  diagnosis  wlu'ii  the  external 
organ  is  aU'ecled.  Any  intranasal  lesion  will  only  be  an  extension 
of  the  external  disease,  the  cartilages  usually  succumbing  to  its  on- 
ward march.  When,  lK)wever,  the  mucosa  is  the  only  part  aU'ected, 
considerable  dilliculty  may  attend  the  diagnosis,  and  the  truth  may 
only  be  readied  by  a  process  of  exclusion.  One  point  should  be 
remembered,  however,  aul  that  is  the  peculiar  softness  of  the  lupoid 
growth.  It  can  be  easily  removed  by  the  si)oon  and  indented  or 
])enet rated  bv  the  probe. 

From  syphilis  it  can  be  distinguished  by  constitutional  treat- 
ment, and  from  tuberculosis  and  malignant  disease  by  the  history  of 
the  case  and  the  general  coiulition  of  the  system. 

Prognosis. — in  all  cases  it  is  a  slowly  progressive  disease,  and  in 
a  large  measure  amenable  to  treatment  when  taken  early.  Very 
few  cases  confined  entirely  to  the  mucous  mendirane  have  been 
reported  as  incurable,  and  they  often  heal  without  leaving  a  scar. 
This  is  not  so  when  the  cuticle  is  the  s(  at  of  the  disease,  as  in  these 
cases  cicatrices  always  are  left  after  the  healing  process  is  over. 
When  the  lesions  arc  extensive,  the  ])rognosis  is  not  so  favorable,  the 
development  being  indicated  liy  the  growth  of  new  nodules,  in  con- 
tinuous succession  into  the  surrounding  tissue. 

Treatment. — Among  local  applications  lactic  acid  is  received 
with  favor.  The  parts  should  be  first  cocainized,  and  then  freely 
rul)bed  with  a  50-per-cent.  solution.  This  can  be  gradually  increased 
to  75  or  100  ]ier  cent.  Care  should  lie  taken  to  apply  it  to  every 
])art  thoroughly,  the  applications  l)eing  repeated  every  second  or 
third  day.     In  some  cases  this  is  said  to  destroy  the  growth. 

Lake  has  had  good  results  from  the  administration  of  thyroid 
extract  in  doses  of  a  little  over  1  gramme  per  diem,  the  disease 
almost  disappearing  under  its  use. 

For  years,  too,  tuberculin  has  been  used  with  more  or  loss  favor 
by  a  number  of  European  writers. 

Of  directly  surgical  treatment,  evulsion  by  Volkmann's  spoon 
or  a  sharp  curette  has  many  advocates — dusting  the  surfaces  after- 


■■'  i 


MiflL 


:;i: 


1 

u 

.:   ■ 

M 

ji 

i 

n 

1 

1^ 


f ; 


i         r 

:| 


118 


UISEASKS    or    TIIIC    NASA  I,    I'ASSACiKS. 


ward  will)  iodoform  or  brushing  tiioiii  with  lactic  acid.  Burning  the 
nodules  down  with  the  giilvano-eautery  is  advocated  by  liresgen. 
Tresilian  successfully  treated  a  case  recently  by  scraping  with  a  sharp 
spoon,  subsequently  burning  it  with  galvanocautery,  and  tlien  brush- 
ing with  50-per-cent.  solution  of  lactic  acid.  Dundas  Grant  also,  in 
one  of  his  latest  cases,  was  eiiually  successful  by  a  similar  line  of 
treatment. 

Glandeks. 

This  is  a  communicable  disease,  peculiar  to  higher  animals,  par- 
ticularly horses,  and  liable  to  spread  to  man  upon  exposure  to  infec- 
tion. It  is  also  contagious  among  men.  In  its  acute  form  it  is  very 
virulent  and  uniformly  fatal.  When  chronic  tliere  is  a  little  more 
hope  of  rccoveiy.  The  usual  site  oi'  attack  is  the  mucous  membrane 
of  the  nose,  from  which  it  may  spread  to  both  pliarynx  and  larynx. 
The  incubation-jieriod  is  fioni  three  to  six  days. 

Pathologically  there  is  a  low-grade  inflammation,  resulting  in 
formation  of  granulation-tissue  containing  large  numbers  of  bacilli. 
The  characteristic  germ  of  glanders  is  the  bacillus  Mallei.  IJapidly- 
spreading  suppuration  and  ulceration  follow  along  the  line  of  the 
lymphatics.  Glands  become  swollen.  Pya?mia,  necrosis  of  bone  and 
cartilage,  deep  abscesses  among  the  tissues,  all  follow.  The  discharges 
arc  also  profu.se  and  oil'cnsive.  The  chronic  form  dilTers  only  from 
the  acute  in  being  somewhat  milder.     (Kyle.) 

Constitutionally  there  is  marked  fever  and  prostration.  The  dis- 
ease may  last  from  fifteen  to  twenty  days,  death  taking  place  by  coma 
and  collapse,  '^rrcatment,  although  practically  useless  in  the  majority 
of  cases,  consists  of  supporting  measures,  together  with  antiseptic  nose 
and  throat  douches  and  sprays.    (Lennox  Browne.) 


CHAl'TKJt  XXVIll. 


RIIINOSCLKROMA. 


This  (lii^cal=o  occurs  but  rarely.  It  i.s  characterized  !iy  the  (U'- 
posit  in  all  the  layers  of  the  i^kln  or  nuicnu>  membraue  of  dense,  hard 
nodes,  or  ])lates.  The  first  deposits  are  usually  in  the  neiyhhorhood 
of  the  nostrils,  gradually  extending  into  the  fossa).  The  ])rogress, 
from  all  records  of  the  disease,  a[)])cars  to  bo  steady,  irresistible,  and 
almost,  if  not  entirely,  uninlhienced  by  treatment. 

Jt  is  believed  to  owe  its  ori,<jiii  {<)  the  rhinoscleroma  bacillus  which 
has  been  extracted  and  cultivated  by  I'awlowsky  and  Freudenthal. 
The  latter  gives  a  coniplete  history  of  a  ease  treated  by  him  in 
189G.  It  occurred  in  a  (ialician  Jew  aged  45.  The  nose  was  of 
immense  size.  The  right  side  ])resented  a  lunior  as  larg(!  as  a  hen's 
egg.  It  was  dark-bluish  red.  with  a  few  vessels  coursing  over  it  and 
of  ivory  hardness.  There  was  a  separate  nodule  in  the  U])per  li|). 
The  right  inferior  turbinated  was  involved  in  its  whole  extent, 
completely  occluding  the  i)assage.  The  pharynx  was  a  nuiss  of  scar- 
tissue,  the  uvula  destroyed,  and  the  naso-j)harynx  and  the  glottis 
almost  entirely  shut  olf,  so  that  a  tracheotomy-tube  had  to  be  inserted 
to  permit  of  respiration. 

There  is  little,  if  any,  pain  in  this  disease,  except  when  the 
extension  of  the  growth  is  very  great.  Then  the  ])hysical  obstruction 
to  mouth  and  nose  may  produce  great  distress.  There  is  no  tendency 
at  any  time  to  ulceration  or  softening  of  the  tissues. 

In  Pean's  case  the  nose  was  surrounded  by  dense  lardaceous 
neoplasm.  The  upper  lip  had  degenerated  and  the  rhinoscleroma 
had  extended  through  the  maxillary  and  ethmoid  sinuses. 

The  pathological  condition  is  believed  to  be  one  of  infiltration 
into  the  afTected  tissue  of  masses  of  small,  round  cells.  These  cells 
are  gradually  transformed  into  spindle  cells,  and  then  into  dense 
fibrous  connective  tissue.  Corneil  found  a  small,  rod-like  bacillus 
inclosed  in  a  hyaline  capsule,  the  same  that  is  spoken  of  by  Freuden- 
thal and  Pawlowsky. 

Treatment. — It  is  usually  regarded  as  entirely  incurable.    Oper- 

(Mil) 


IP 


:i;i 


150 


DISKASKS    Ol'    TlllO    NAh.VI.    J'ASSAUKS. 


It 


4 


■n 


ativc  trcaliiii'iil  lias  so  little  circct  that  it  is  considered  useless,  except 
when  reiiuired  to  restore  the  possihility  of  rcsi)irati<m.  Internal  medi- 
cation is  also  useless.  Xotwithstanding  this,  Dontrelcpont  reports  a 
cure  from  the  application  dI'  a  J-pcr-ient.-corrosive-suhliniate  oint- 
ment twice  a  day  J'or  three  and  one-hall'  ninnths.  As  Hoswoith 
remarks:  '^May  this  not  have  ln'cn  a  syphilitic  <ase  cured  hy  mer- 
curial inunction?'' 

I'awlowsky  treated  two  cases  hy  hypodci'niic  injections  of  rhino- 
sclerin,  or  the  ihcinical  I'stract  of  ciillnrc-  of  rhinoseleronia.  The 
injection  of  the  extract  in  a  jiaticiil  IS  years  old  produced  feverish 
reaction  and  swcllin<;'  of  llie  alVected  nose.  A  month  later,  after 
1")  injections,  the  phK/iirs  were  softened  and  tluic  were  si^^nis  (jf  acute 
intlammation.  lie  treated  this  case  for  a  year,  aiul  duriuff  that  time 
th.e  disease  had  not  advanced.  In  a  second  case  treated  t!ie  same 
way,  although  it  was  not  cured,  there  v/as  during  six  months  no 
increased  development,  llcnce  the  author  helieves,  from  the  history 
of  these  two  cases,  that  he  has  focd  in  rhinoselerin  a  diagnostic 
and  therapeutic  agent  for  this  disea.-i  . 

Tean  tried  surgical  treatment  in  the  case  of  a  woman  aged  20. 
ViV  extensive  operation  he  removed  the  nose  and  all  the  upper  lip 
and  the  turhinatcd  hodies,  resecting  the  ascending  part  of  the  maxil- 
lary hone  and  curetting  the  antrum,  lie  approxinuited  the  cutaneous 
flaps.  All  that  was  left  was  a  large  hole  in  the  middle  of  the  face. 
Subsequently  cauterization  of  suspicious  parts  was  jjcrformed  with 
Cancpioin's  paste.    How  long  the  ])atient  lived  we  arc  not  informed. 


('ii.\i''n;i;  xxix. 


SVI'IIII.I>. 


'I'liK  iiidiciitiiitis  ul'  sy|iliili.-  in  the  nasal  [nv-sa^fs  arc  identical 
with  llicir  local  nianil'cslatidn.-  in  the  Ktlicr  or;^aii»  nf  the  ImkIv,  ami 
iK'cd  not  lie  cntcicd  into  uiinnicly  licrc.  '["he  primary  lesion,  or 
hard  clianci'c,  i^  one  of  the  rarest  ol'  intraiia>al  lcsion>.  Siill.  eases 
are  rccoidcd  of  it>  occuri'ence.  Its  hi.-tory  and  apiH^arancc.  aided  hy 
til.    process  oj'  excliisii)n,  shnnld  render  its  reco^iiiitioii  ca>y. 

The  nuicous  patch,  allhnn^^li  rare,  is  one  oi  the  most  lrc(|nenl 
iiiaiiiJ'ostatioiis  ol'  early  syphilis  in  ilii>  reL;ion.  'I'ho  tendency  of  the 
disoiisc  to  tievehtp  at  the  nuico-cutaneon-  horder-lines  of  the  lip  and 
iiii.^tril  exists  here,  as  at  the  anus  and  vuUa,  although  in  the  former 
rc<;ioii  the  cases  arc  very  infieijucnt.  hivasse  and  Devillc,  in  re- 
porting' iSd  females  siilVerini;'  froni  mucous  patch,  onlv  found  S  in 
which   the  patch   all'ecled   the   nose. 

'J'he  superfiiial  (deer  i,-  iielieved  liy  many  to  occur  (Uily  in  the 
secondary  sta,i;e,  \\\<<  or  thicc  years  after  ilu'  primary  sore,  and  to 
he  caused  hy  the  softening-  ami  l)reakin;^'  down  of  a  inm-ous  patch. 
IJosworth  l)elieves  that  it  helon^s  to  a  later  dale  of  the  di-^ease,  and 
is  the  re.-nli  of  softening  and  erosion  of  su|)erficial  jiiimmatou.*  de- 
posit; particulai'ly  as  the  latl'  r  j^ivi's  so  little  indication  of  its  \)vv>' 
eiice  that  it  may  he  ovi'i'looki'd  until  the  attention  is  drawn  to  the 
more  notahle  features  of  the  i'ully-developed  idcci'.  The  site  of  >uper- 
licial  ulcer  is  usually  the  septum  or  the  llooi'  of  the  nose:  hut  this 
is  not  invariahly  the  case.  At  the  ju'cscnt  time  I  have  a  patient,  a 
niarrie(l  man,  who  has  superlicial  uIcim'  of  the  left  miildle  tui'hinated 
and  also  of  the  po>t-pharyn,L;'eal  wall'. 

liony  necrosis  is  a  residt  of  e\ten>ion  of  deep  ulceration,  throiijih 
gummy  dejiosit,  and  hence  is  of  a  ti'rtiary  nature.  Amonii  Kuropean 
races  it  occurs  ten  or  lifteeii  years  after  tlu'  primary  disease.  Amon<,f 
some  of  the  earlier  races,  particularly  the  Chinese.  Aral)s.  and  Mexi- 
cans, the  disease  is  more  virulent  ami  runs  a  more  rapid  course. 
Most  of  these  hony  lesions  occur  u])(Ui  the  septum,  the  tnrbinateds 
comin<;  ne.xt;  that  is.  when  the  muio-cutaneoiis  surfaces  are  not 
invaded  first. 

1"  ( 1 :.  1 ) 


168 


i)isi;.\si;s  oi'  Tin:  nasai-  i'AssA(ii:H. 


Pathology. — Syphilitic  lesions,  ulicrcvci'  foiiml,  nic  nil  nl'  nii  iii- 
flinniniitory  (•luii'iictcr,  and  the  iiasnl  piissii^jt's  nro  im  cxci'ptinii  to  ilio 
rule.  In  primary  lesion  of  tiic  nnsal  imieoiis  nieniliranc  tlie  t'el)rilo 
action  rnns  liijih,  and  tho  nicer  may  present  n  lariro  (granular  mass, 
filling  np  the  nostril  and  eaiisinj;;  deformity,  while  the  sli;;litest  press- 
nic  may  |ir()diic(!  hloedinj,'.  Tho  mucous  ])atch  and  the  siiperlieial 
ulcer  will  (lill'er  little  from  their  appearance  in  other  reuMons.  'There 
need  lie  no  j;reat  thickeiiiiiix  without  the  ulceration  arises  from  an 
Pidarired  ;;umma,  the  chief  stenosis  hein^'  caused  by  the  ahnndance  of 
miico-pus  constantly  secreted. 

When  the  <:ummy  tumor  forms,  it  iiulieatcs  an  active  condition 
of  the  tertiary  slaij,i'.  Tliei'c  may  he  lar;;'e  deposit  of  ;:,ununatous 
nuiterial  with  infiltration  or  tumefa(;tion  of  the  mendiraiu".  Xo  part 
of  the  nasal  cavity  may  escape  tlie  deposit.  'J'he  ulcerative  ])rocess 
early  invades  the  gumma,  and  bone  as  well  as  cartilage  nuiy  soon  ho 
involvi'd. 

Sometimes  surface-ulceration  ends  in  resolulinn  and  culminates 
in  cicatrization;  hut  in  the  majority  of  eases  the  underlying  peri- 
chondrium or  periosteum  ])nrtakes  in  the  ulcei'ation.  and  necrosis  of 
lione  or  cartilairc  f(dlows. 

Symptomatology. — When  the  disease  is  jirimary — that  is,  the  re- 
sult of  direct  contagion — the  ordinary  syiujitoms  of  chancre  may  he 
expected,  oidy  in  an  aggravated  degree.  There  will  he  intlammatory 
swelling,  pain,  diilieult  nasal  breathing,  discharge,  and  considerable 
fever. 

In  tho  secondary  stages,  a.s  variously  manifested,  there  will  bo 
coiyza  from  mild  to  purulent.  The  mucous  membrane  will  b(^  luifTy, 
red.  and  congested,  (ireenish-yollow  pus  will  exude  from  the  nos- 
trils, and.  after  thorough  cleansing,  ashy-gray  patches  nuiy  sometimes 
be  seen. 

In  tl;e  tertiary  type  ulceration  is  deep  and  formidable,  heing  snr- 
roiimled  by  ragged  oi\^j:v<  and  an  angry-hiokinu:  areola.  The  cartilages 
and  bones  being  involved,  foul,  offensive  ]nis,  with  shreds  of  necrosed 
cartilaginous  and  os-((iu>  tissue,  come  away,  until  eventually  both 
oaitilage  and  bdiie  may  lie  destroyed,  leaving  unsightly  facial  de- 
formity. In  the  sevei'est  cases  the  triangular  cartilage,  ]U'ri)endieular 
plate  of  the  ethmoid,  vonu'r.  and  even  the  turl'inateds  are  all  in- 
volved in  the  ruin,  nothing  bnt  Chinese  '■nose-holes'"  being  left — 
more  apertures  in  front  of  an  irregularly-flattened  face. 

In  one  case  that  came  under  my  observation  the  whole  of  the 


sv  I'll  I  LIS.  |."i;! 

iiitonial  ii;i-iil  stnictnroa  had  l)oc(niio  ilctiiclu'd  from  tlii-ir  HtirroiiiKl- 
iii;:s,  and  rormrd  iiiln  a  Ihiltc,  I'li'tiil,  iuovmIiIc  iiias.-;.  'I'liis  oiciinril 
it!  ii  iiiiirricd  woiiiiiii  ii^^t'd  iiliniit  .'!(»  vtiii-;.  'I'lic  cutidil  imi,  I  \\a> 
iiironiH'd,  Iiad  cxisliMl  lor  a  miiiilit'r  nf  years  ami  slic  was  iml  rcfcrrnl 
for  spt'ciiil  ti'calmtiil  until  a  small  |i('ii'nratiiui  thiiiii^li  the  haul 
palato  liad  rormcd,  allnwiiiu'  the  iu'tiil  secretions  to  tiiekle  tliroui;li 
into  the  mouth.  The  Ireatmeiit  ennsisled  of  lueakiii^'  up  the  mass. 
CN  tract  in.!.,'  the  I'raLiineuts  throuj:h  the  anterinr  narcs.  and  wasliin;;'  out 
the  ca\iiy.  Internally  the  syru]i  of  the  indidr  of  iron  was  adminis- 
tered. 

Diagnosis.-  When  all  other  diseases  have  hcen  put  aside  by  a 
procc.s.s  of  exclusion,  a  n^sort  to  conslitiit  ional  treatment  my  help  In 
remove  nil  I'eiuiiinin,!:'  doidd  as  to  the  true  nature  of  the  disease. 

Prognosis.-— 'I'll is  (h^pends  lar;;-ely  upon  the  i'.\tent  and  severity 
of  ihe  loioiis.  If  the  ,i:enei'al  health  ha.-  imi  materially  .-ull'ereih  ami 
tile  lesions  aic  of  a  superlicial  character,  treatment  slmuld  he  fol- 
lowed liy  the  hes;  results.  I'lven  when  houe  and  cartihijie  have  he- 
roine inv(dved,  when  this  destruction  i.s  nn'rely  local  it  may  l)e 
possihle  to  arrest  it  in  its  pioyress.  And,  even  in  the  wor>t  case-^, 
.■-ome  little  <itnn]  may  he  expected  from  judieioiis  ami  careful  treat- 
ment. 

Treatment. — This  is  one  of  the  few  Tiasal  alTcctions  in  which 
systemic  medication  is  ahsohilely  essential  to  eU'ect  coniplete  rescdii- 
tion.  Specific  treatment,  aided  hy  soothiiiL;'  and  cIcausiiiL:'  lavaire  of 
the  nasal  fossa',  will  in  many  cases  ell'ecl  a  cure.  'I'lic  main  thiii^ 
is  to  commence  the  internal  treatiiicnt  at  once.  Tluii  the  local  treat- 
iiiciit,  to  he  uuideil  liv  Ihe  reipiireuients  of  the  case,  after  wasliiii;^ 
out  the  nasal  cavity  with  a  solution  of  Koric  acid,  hy  means  of  an 
atomizer:-  - 

1.     11   .\ci(l.  I.mic !« 

A(|ua    'Mil 

Arislol  oi'  ioilo]  miuht  he  thi'own  into  the  fossa>  hy  insuniators, 
or  the  parts  miuht  he  touched  with  tincture  of  iodine.  Nitrate  of 
silv(M'  fused  on  the  end  of  an  aluminum  ajiplicator  will  fr'Mpieiitly 
control    ulcerative   acti<m.      rtalvanocauterization    is    I'arcly    ne<'essary 

1.     R   Aokl.  borip pr.  x. 

Aqua 5j. 

M. 


m 


•  ii 


I 


ir;  n 


ioi 


niSKASKS    ;H'    ■lUK    NASAI.    I'ASSACKS. 


ill  this  ili.-i'ti.-''.  Ill  .-oiiir  i-asr-  of  t'Xtcn.-ivc  uli  (.'lalidii  liizlil  .-iiiiiciny; 
(if  tlu'  ])iirls  exercises  a  {■onli'dlliiii;'  iiilliieiiee. 

As  til  iiilenial  iiiediealiim.  Sajous  I't'coiiuiieiiils  red  iodide  of  nwv- 
ciiry  ill  doses  of  I  iiidli,i;rah;iiies  three  times  a  ihiv.  parlieiilarly  in 
.^ecfindary  all'eeti(iii>.  After  |ityar,.-iii  ha.~  oeeiirred.  he  substitutes 
iodide  id'  |)iita.->a  for  llie  |iiir|)oi'  of  I'liiiiinatioii.  In  the  tertiary 
form  niereiiry  is  le.-.-  ell'eelive  tliaii  the  iodide,  whirh  shiudd  he  uiveii 
in   full  doses  to  produci'  tlie  ih'sii'ed  result. 

When  merenrials  are  reijuired.  it  matters  little  what  ,-i)eeial  form 
is  used.  The  main  features  are  to  choose  the  |ire])arati(>n  least  oh- 
jeetionalile  to  the  stomach,  to  ,i:ivi'  d  in  minute  doses,  and  to  watch 
its  ellVet.  kee|iin,a-  its  inlliieiice  iij  i  the  systi'iii  tlioroiiidily  under 
control. 

Wliou  osseous  or  cartilaginous  necrosis  takes  place  the  hreaili 
becomes  horri^  \y  oll'ensivi',  and  ojierative  jirocedure  may  become 
necessary  to  save  the  patient  from  absori)tion  (d'  necrotic  material. 
The  sharp  spoon  or  curette  in  these  casi's  will  do  the  liest  service, 
billowed  by  thorougli  antise]ilic  and  ase|)ti<'  Ireatmi'iit. 

Suiiporting  measures  in  the  way  of  tonics,  codliver-oil.  good 
diet,  daily  baths,  warm  (dotliing,  abundance  of  jinre  air.  and  thor- 
ouglily  hygienic  surroundings  are  all  of  essential  benefit. 


(HAITI-;  11  \,\.\. 


(()N(;i:\iT.\i.  svriiii.is. 


I'!! 


T  is  .-till  iiii   imx'ltird  (|iif.-iinii   u  hcilii'i'  ;i  >y|iliilinr    lallic!'  ciiii 


triiii>i.iil   the  disciix'  III  hi-  rliilil   wiUidiii  alirctiDL;   t!ic  iiit'ihcr  at    Ilir 


sail. I'  nine 


It 


!i'V('(l 


iMiwcvci',  llial    if  iMlhcr  iiarciil    i-  a 


liVctrd 


iiv  the  (lisca~c  al  lln    liiiic  nf  iiii|ii'c,i:nal  inn.  ilic  unrnininalc  nlV.-pi'iiii:' 
will,  as   a    rf,i;-c(|llc|ici',    he   the  .-iillVrcr. 

Symptomatology,     ('nrvza.   inuciiHT   wiih   sniiic  (lill'n^c   U>v\\\   d 
(•iilani(iii>  i'rii|il  iui).  is  ii-iially  llic  carlicsl   .-yiii)i|oin.     The  cnryza.  a- 


a  rule.  i>  watcrv  .al   liisl. 


"here  is  also  -wrlliiiL:  "\'  t  ln'  iia^al  i 


lHirii>a. 


pullicii'iit   lu  iiii|u'(lr  ur  |ir('\cnt   iia-al  rc-piral  inn.     (iradiially  the  di-- 


•liar* 


,e  Itcfdiiics   imic()-|>nnil('iit,    |ir(idii(inL;    irnialinii   id'   llic   ikisIimI 


iutd  ii))]i('i'  lip.  will)  (  rii>t-l'()i'inati(in.  'Plic  di-(liai^;('  i>  ir.orc  irrilat  Iiil: 
than  llial  |irndii(i'd  liy  an  nnliiiiirv  cold.  Syphilitic  cliildrcii  arc  .ipl 
til  lie  pale  .■mil  cadavcrmis  InnkiiiL:',  and  may  liaNc  the  wilhered  Innk 
of  a^>i'  e\('ii  diirin^'  I  lie  lirsl  year.  'Tin-  inav  lie  partly  due  In  iiialiilily 
to  take  a  jirnper  ainnnnl   nf  nnnrislinient.   t'l'mn  the  Inn-id'len  careless 


iiiotlier,  iiwiiiu-  to  nasal  -tcnn>i<  pnidiu 


Iiv  iI 


le   ijl-casc 


( 'iiii,u'enilal  syphilis  ol'  the  nns 


e  iisnallv  run-  ;,   rapKl  cmirse 


many  ca>es  ulcci'aiKin  nl  the  ,-cptiiin  ;ind  nasil  carlila^'es  (niickly 
follow  the  ciiryxa.  r>iine  is  laid  hare.  .-loii;:hiii,i;  id'  I  issuer  and  nc- 
cfosis  of  lione  niav   i'nlliiw.  with  I'lclid  catari'h  and  dcd'oriiiiiv  as  direct 


results 


of  ti 


le  dcl'iirmitv  of  >addle-liaek  iin-c.  lu'oduced  liv  destniclion 


le  septum  and  -inking'  in  of  the  ti.-sues.   fi'cipicntly  has  its  o:'i;;in 


111  inlu'rited  t( 


VI  lai'v  disease  of  childhi 


iiirse  of  the  disea-t 


is  more  rapid  in  infantili'  than  in  adult  life,  owinu'  in  ihe  lessened 
power  of  i-e-i,-i,ince  which  cxi-is  in  ynniiii'  children.  .\mon,L:  ihc 
(■ui'ions  results  nf  tiiis  di>case  is  one  reported  hv  (iilili  W'isharl.  in 
wliieli.  toiicthei'  with  ureat  dot  met  imi  nf  the  hoin  frainc-wnrk  of 
the  nose,  there  is  alxi  Ihe  dcvelopnicnl  of  a  lonih  within  ihe  iia-al 
fossa. 

Diagnosis.  -In  the  otlierwi,-e-heallhy  child,  oidinary  aciiti'  ca- 
tarrh of  ihe  nasal  passa,i.;'es  speedily  uiuleffroes  resnluiion.  Syphiliiie 
rhinitis  of  childhood,  on  tlic  otiu'r  hand,  is  noted  fnr  its  continuity 
and  the  severity  of  its  symptoms:    also  for  tlii>  iinhcallhy  cachexia  of 

(I.'.:.) 


i: 


I  i 


IjG 


DISK.VSKS    Ol'     I'lIK    NASAI.    I'ASSAC  KS. 


its  victim.-.  Tile  diiiLMiu.^i.s  irniii  nrdinary  purulent  i-hinilis  of  cliild- 
liood  .should  lint  lie  dillieult,  as  syijhilitic  I'liinitis  will  be  iiiauii'e.^t 
duriiii,''  eailv  inlancy.  whereas  purulent  ihinitis  d()e>  not  usually  ap- 
])ear  before  the  third  year.  The  syijhilitic  eaehexia,  and  the  ehar- 
aoteriitic  cutaneous  erujition,  absn,  do  not  ])resent  theni.^elves  in  the 
milder  disease. 

Prognosis.-— The  eailiei'  the  po.-itive  symptoms  appear  in  the  life 
(d'  the  infant,  the  niori'  severe  the  disease  and  the  less  the  prospect  of 
recovery.  When  tlu'  symptoms  are  nuniifcst  at  first  nasal  stenosis  is 
nsually  so  great  as  to  inierfere  with  nursing.  ^lalnutrition  i-  the 
result,  with  eonse(pient  decay  in  vitality.  The  nasal  septum  sonn 
idccrates  away,  and  falling  in  of  the  bridge  may  be  the  result,  if  the 
little  ])aiient  survives  long  enough  to  experience  the  deformity. 

On  the  other  liand,  if  the  diseaso  is  lighter,  the  s}mptoms  ap- 
pearing later,  the  nasal  tissues  may  not  be  destroyed,  and  uiuler 
proper  treatment  there  is  hope  of  cure. 

Treatment. — Cleansing  and  soothing  treatment  of  the  irritated 
and  intlamed  nuicons  niemljrane  is  very  important.  To  shrink  the 
swollen  tissue,  by  diminishing  turgescence,  and  at  'he  same  time  to 
lessen  the  sensibility  id'  the  nerve-filaments,  the  use  (d"  a  weak  solu- 
tion of  cocai.ie  is  advisable.  In  making  the  snliition,  however,  it 
should  be  retuembered  that  muriate  of  coeaine  and  biborate  of  soda 
are  incompatible,  an  insoluble  borate  of  cocaine  being  at  once  formed, 
iiicarbonate  of  soda  and  muriate  of  cocaine  are  also  incom])atibIe,  the 
cocaine  alkaloid  being  de])osited,  and  chloride  of  sodium  being  left 
in  solution. 

EitluM'  of  the  I'nlldwing  ]irescriptions  would,  however,  answer 
the  ])urpose:— 


1.     Ft  Cocaine  liyiiriirliiiii- 

Acid.  I)(iiic 

.\(|uam    iul  30 

W. 


Iiut 


Mithei'  (d'  these  nnght  be  used  as  a  spray  to  the  nares 
))etter  plan,  according  to  my  experience  with  young  children,  would 
be  to  apply  it  Iiy  means  of  a  pledget  of  w>:o|  upon  a  cotton-holder. 
Witli  the  child  in  the  recundx'id  po>tui'e,  it  can  be  placed  uitliin 
the  nostril  mnic  elfeelually  and  will  be  received  with  less  opposition. 

1.      H  ('oi'iiiiic  liydidihlor <sr.  iij. 

.\ci(I.   Iioric <.'r,  vi j. 

.\(|\iioii     ad   5i. 

M. 


COXOKNITAL    SVl'llU-iS. 


IT)? 


Or 

1.  IJ  Cocaine  liydidclili))' 12 

Amnion,   liydrcx-hlor 3 

Aciiiaiii     iid  ;il)| 

M. 

!iii,i;lit  ])('  used  in  the  saiiic  wwy. 

TluMi,  afU'i"  tin.'  slii'iiikage  of  llic  nasiil  iiiiico^a  which  a  t'ow 
iiiimiU's^'  iictii)!)  (if  the  (•ocainc  woiihl  ]in)du(M\  tlie  following  or  some 
similar  prt'iiaralioii  ii)i_i:ht  be  applied  in  the  same  way: — 

2.  H   Tliyni.il    '13 

Mciitliol  J3 

Albolcne    :W 

Tile  parts  hy  tliis  lime  hriii^'  amestlieli/.ed.  the  child  will  proh- 
jihly  submit  to  I  ho  use  of  the  spray,  if  not,  the  cotton-holder  can 
be  used  with  this  solution  as  before,  pressing  it  gently  through  the 
nostril  to  better  cleanse  the  passage.  If  sneezing  is  })rodueed  by  it, 
a  good  pur])ose  will  have  been  accomplished,  as  the  sternutatory  etforts 
will  involuntarily  clear  the  nostrils  of  sectrctions. 

As  a  local  application  to  the  u]iper  lip  and  intlamed  anterior 
nares,  the  following  has  a  soothing  ell'ect,  applied  as  ..ften  as  re- 
quired :• — ■ 

3.  R  Unp.  zinci  nxidi    HI 

Vasclin    allia    H; 

M. 

For  ulcerative  action  wiiliin  the  Ud.-trds  ai'i>l(i|,  iodol.  lodnform, 
etc..  may  any  of  them  be  npcd  by  insufllation  after  cleansing. 

This  trcn'meiit.  while  lienefieial  to  the  local  manifistation  of 
the  ditieasf',  can  do  nothing  Inward  eradicating  it   from  the  system. 


■'la 


iill 


m 


UVil 


m 


:W}:  |l 


1.  R  Co^  aino  hydrochlur pr.  iij. 

AniTTKin.  li.\  driM-liIdr jrr.  v. 

A<4i«iiin  ad  ,^j. 

M. 

2.  It  Tliyimd  yr.  ij. 

Mfntliol  jTf    V, 

A  Ibolciif fi; 


3.     I{    I  r,ff.  ziiici  oxidi 
N'.iHolin  all)a   .  . .  . 
M. 


Sij. 


!li 


lofS 


l)isi:.\si;s  OK    iiii:  nasal  passages. 


This  citii  Hilly  111'  acroiii]ilislie(l  liv  constitutional  iiu-ans.  and  tlio  best 
111'  tliL'sc  is  tlif  iiitcniiil  iidiiiinistration  of  inc'i'onry.     This  can  usually 


)L'  acfoniplislic 


\>\  the  stomaeli.     Minute  doses  of  anv  of  the  uu.t- 


curioals  iiiav  lie  irivcii.  aovcrnt'd  l»v  the  lixnl  nilt'S  which  jruide  tlic 


ad 


ministration  df  these  driius.      li'  tlie  stomach   is  disturbed  liy  tin 


mercury,  inunction  may  possibly  yield  better  results. 

(icncral  rules  with  reuard  to  food  ano  hygiene  .-hould.  of  cour.so, 
ho  enforced. 


i:;!;! 


DISKASKS   OF  'I'll!':   ACCKSSOiJ V    SINTSKS   OK   'nil':    N(»SK 


(•IIAI''l'Ki;   XXXI. 


A(  ITK  SINrsiTIS. 


T   IS   ii'ciu'i'iillv   (•(iinciii'il,   wi'ii    i'ci:;inl    In   chi'iiiuc   inllniiiinntinn 


of  (lill'i'i'ciit  rt'uidiis  (if  ilii'  iKiX'  iiiul  Uu'diit. 


;is  Well  ;is  iiUlfr  oruMlls  nl 


th 


c   liodv,  that   thcv   iiiu~l    nf   iicii'ssitv   nc  priccdcd   liv  iiciiti-  inliiiiii- 


iiiatorv  actioi 


1  (11  iiiic  tni'iii  di'  aimthcr. 


W 


IV  diseases  of  the  aiit  fiini. 


ethmoid 


cells,  and   s|ilu'ii()id   .-inns  slniuld    lie  i'\cc|itii)ns   to  this  rnlc 


it  is  dillicult  to  say. 

As.  Lennox  lirowiie  teisily  says,  •'.Vcute  sinusitis  is  fri'qiii'iil." 
altliongli  the  I'aer,  for  which  ahnndant  proof  has  hcen  liiven,  is  not 
as  yet  generally  admitted. 

Weichselhanni,  of  \'ienna.  perfoi'med  autopsies  upon  tlu'  imdies 
of  a  large  nuniher  of  patii'nls  who  hail  <lied  id'  inlluenza.  In  Hit 
per  cent,  of  these  he  I'ound  evidences  id'  intlanunation  of  oiu'  iw 
other  of  the  ae<'essorv  sinuses. 


Friinl< 


el,   ot 


llai 


nionrg.    likewise    perlorineil    antop-ies    iipiui    the 


bodies  of  Mii  pativ'nts.  followed  liy  t)acteriological  examinations  i\\' 
the  contents  of  the  sinuses.  'I'iiey  were  fonnd  to  he  all  suhjects  of 
sinusitis  withont  one  of  them  heing  diseoM'icd  during  life. 

J>acteriologieal  I'xaminiUions  have  proved  that  nunier<in,-  hacilli 
enter  into  the  development  of  acute  .«inous  disease.  .Among  these  are 
the  diplococcns  laneeolatus  in  the  pnciinioinc  torin  (d'  antral  disease. 
Streptococcns  is  sometimes  found  in  pure  culture.  Staphylococcn- 
is  nsnally  associated  with  the  other  mganisms.  Ilacillus  pyogene- 
ftetidns,  hacteriuin  coli.  and  . I. v/^c /•'//'//»>■  finiiujiilii^  have  all  hcen  dis- 
covered in  some  eases. 


Etiology. — .\cute  eiidorhinit 


IS,  or.  a>  It    IS  u.-uallv  e 


aciiti 


rliinitis,  is  the  most  rrc(|uent  canso  of  sinoiis  disease.  Next  to  thi- 
may  he  considered  the  infections  diseases:  scarlet  fever,  measles, 
tyjihoid  fever,  and  small-po\.  .\nother  cause  not  >u(heiently  appre- 
ciated liy  the  professicm  is  the  presence  (d'  lampons  (d'  ali>orhent 
cotton  within  tli(>  nasal  cavities,  placed  there  hy  the  surgeon,  either 
to  check  lu'emorrhage  or  as  an  after-treatipent  following  operation. 

(l.-)!M 


I' 


IGO 


DISK.VSKS    OI-    TllH    NASAL    TASSACKS. 


ni^i 


\Ut 


9    I 


A  si'Vcit'  ciisc  (if  acute  |iiiriilciit  .-iiui>ilit;,  iirisiiiu'  from  the  liist- 
montioncd  oauso.  canio  rocciitly  iimlcr  iiiv  ohscrvatioii.  Jt  occuriL'd 
in  a  ])Iiysieiaii  a^ed  40.  Tlio  syinptoins  wx'vv  rulliic'ss  and  lu'avino.-.s 
in  the  ro^don  of  tlie  antrum,  with  coj)ious  discliarge  llirou.iih  tlio 
ostium,  ))articularly  upon  Ijcnding  forward.  The  antrum  healed  up 
in  a  sliort  time  without  any  special  Iroatnienl  oihi-r  than  that  re- 
quired for  an  ordinary  eohl. 

The  maxilhiry  anti'um  is  the  sinus  usually  all'ccted  in  this  dis- 
ease, though  sometimes  the  ethmoid  eells  may  be  the  primary  seat 
of  lesion.  Sometimes  the  inllammation  may  atlaek  the  two  success- 
ively. 

Symptomatology. — The  subjective  symptoms  are  tisually  those  of 
acute  nasal  catarrh,  atfecting  llie  one  side  ])articularly.  There  may 
he  neuralgia  in  the  region  of  the  orliit,  with  photophobia  and  lacry- 
mation,  together  with  a  general  fejling  of  malaise.  These  symp- 
toms appear  to  he  amenable  to  treatment. 

Physical  examination  without  first  applying  cocaine  to  shrink 
the  tissues  will  usually  be  without  avail,  owing  to  the  swollen  con- 
ilition  of  the  mucous  membrane.  .M'ter  the  shi'iid<a'ie,  however,  if 
suppuration  has  occurred,  the  middle  turbinated  of  the  all'ected  side 
will  be  seen  more  or  less  bathed  in  pus.  There  will  likewise  he 
tenderness  on  pressure  uj)on  the  all'ected  side. 

The  majority  of  cases  of  acute  sinusitis  get  well  without  treat- 
ment, for  the  simple  reason  that  they  jjass  away  without  ever  being 
discovered.  Still,  it  is  very  ])robable  that  a  large  number  of  cases 
of  chronic  sinusitis  have  originated  in  the  acute  form,  which  by 
timely  treatment  might  have  been  arrested. 

.'\s  Lermoyez  has  well  said,  acute  sinusitis  is  almost  invariably 
amenal)le  to  cure  without  operation,  ^\■hile  in  chronic  sinusitis  no 
I'cmedics  are  available  except  the  surgical. 

Acute  sinusitis  is  supposed  to  last  about  eight  days,  subacute  is 
(>.xtended  to  two  or  three  weeks,  while  a  longer  existence  merges  it 
into  the  chronic  disease. 

The  ])roportionate  danger  arising  from  acute  inflammation  of 
the  antrum,  ethmoid  cells,  and  sphenoid  sinus  is  in  the  invi'rse  ratio 
to  their  fre(iuency.  Acute  disease  of  the  antrum,  although  the  most 
frequent,  is  the  nuldest  i  ^  'ype,  owing  to  its  greater  distance  from 
the  meningeal  nii'nibranes.  The  ethiuoiditis  is  more  severe  on  ac- 
'  onnt  id'  danger  of  inducing  basic  meniugitis  and  orbilal  (oMiplicn- 
tions,  while  acute  inllamnuition  of  the  s])henoid  sinus,  although  so 


ACUTE    SINL'SITIS. 


1(11 


I'are  as  to  be  almost  unknown,  is  supposed  to  l)e  the  gravest  of  all 
when  it  does  occur,  owing  to  the  pnssibility  of  inducing  cavernous 
tjirombosis. 

Treatment. — This  should  lie  along  tlie  lines  alreadv  iiKlicated 
for  the  trratmcnt  of  acute  rliiniiis.  Mild  catharsis  in  the  coninicnce- 
iticnt  of  tiu'  di-ease,  followed  by  V '.,-graniiii('  doses  of  (piiiiinc  two 
or  three  times  a  day,  together  with  tablets  for  the  night-time,  com- 
posed each  of  y,  centigramme  of  morphia  and  '/,„  milligramme  of 
atropia,  rej)eated  every  two  or  three  hours  until  sleep  is  induced, 
may  be  considered  an  advisable  course  of  systemic  treat uieid.  When 
fever  is  ])resent  droj)-doses  of  tincture  of  aconite  eveiy  hour  has  a 
good  effect. 

Local  treatment  by  •■3-])cr-cent.  spray  of  cocaine  will  relieve  the 
intraiuisal  congestion,  the  astringent  t-lfect  of  which  may  be  prolonged 
})y  following  it  with  sj)ray  of  2  ]jer  cent,  of  menthol  in  alboleiu'.  This, 
repeated  as  often  as  required,  will  bivor  free(loin  of  discliarge  and 
hasten  the  liealing  process  as  the  slight  fever  al)ates. 


Ill 


m 


(  IIAI''I'KK   XXXII. 


(  lli;n.\|c   DISKASK  oi'  'IIIK  A\l  Itl'.M  OK  II  l(;il.M(  tl!K 


'I'lii-;  aiili'iini  dl'  1 1  i^lmini-c.  lifiiiii,"  llii'  liiru'c-^l  nl   llic  nasal 


accc: 


sory  siniisfH,  and  the  mic  iimst  IVci|U('titly  ail't'clcd  with  ])iinili'iil  dis- 
ciisc.  is  worthy  of  ilic  most  carct'iil  ciinsidcial  i(m  (l'"i,L;'.  •!'').  'I'ln'  term 
indicalcs  a  chriiiiic  iiillaimiiatdiy  cuiidiiiiin  id'  tlic  iiiiicniis  niciiihranc 
lining:  the  -ii|H'i'i()i'  iiia.xillaty  sinus,  attciidi'd  Iiy  llic  roi'inalioii  nj'  |iiis. 
'I'liis  irradiially  lills  the  cavity,  and.  liavint;'  no  otlici'  outlet,  when 
the  |iurnlcnt  matter  I'eaelies  the  iiei^iit  ol.'  the  ostium  maxiUare  it 
tri(d\k's  over  into  the  ini(hlle  meatus,  heiieath  tlio  middh'  tnrhinated 
body,  and  is  dischar,ii('(l  Ky  the  anterior  and  [toslerior  iiares. 

Pathology. — .\l    tlie   comineiicement    (d'   the   disea>e   the   mueons 
mendirant'  id'  the  anli'uni  is  sli,Lilitly  swollen  ami  hypeiu'nuc.     Some- 


l'"i.<.'.  (i.").     ('ii-i'(nw  mass  wiislii'd  eut  of  aiitnini  tludii^'li 
(istiiiiii  iiiaxillariv 


times  the  hlood-vessels  lupture  in  dilVerent  ))laces.  caiisinii'  little  spots 
of  eccdiyinosis.  .\s  the  disi'ase  advances.  tli(>  meiid)rai)e  ihitdveiis, 
ill  some  cases  hocomiiiu'  infiltrated  and  in  others  covered  with  granu- 
lations. Xot  inl're(iueiitly  (edematous  nodules  form,  which  in  tinu' 
take  on  the  myxomatous  aspect,  until  clusters  of  small  polypi  may 
he  found  lian.uin<:  round  the  internal  horder  id'  the  ostium.  Kantliack 
records  a  case  (d'  polypoid  growth  within  the  anti'um.  Synionds 
found  several  in  one  antrum  varying  hetween  one  and  two  centi- 
metres in  length.  i\oth  says  antral  polypi  are  scarce.  In  the  Ainnils- 
of  ()j)]ilJi(ilni(ili>iiii  (Hill  Oliihiijii  for  lS!>ti  1  repoHcd  a  ca>e  in  which 
what  seemed  to  he  s(d't  p'>lypi  were  washed  out  thrfuigh  a  large 
hiatus  semilunaris,  the  nozzle  of  the  syringe  being  placed  in  one  end 
of  the  passage.  The  accompanyini:  cut  (fig.  ()."))  gives  the  exait  size 
of  the  largest,  after  being  in  alcohol  over  two  years  ^licroseopical 
(l(;v?) 


il;    ^i,,  i! 


I-'Il;'.  lili.  Liitciiii  liii/cii  -cciidii  iIii<ium1i  tlii'  iiiiildic  rruiinn  nl'  tlir  iiu-r. 
I.  Klliiiidiil  fell-.  \i.  Su|iirini-  t  nrliiiiiitnl.  :;,  Mi, Idle  i  inliiiniird.  1. 
Aiitnmi  lit  lliiiliniiiic.  ."i.  I  nidii,  (n  ^viiriliiii.  Iiriwci'ii  -i'|ituni  :n\i\  inlciiiN' 
1  iirliiiKilfil.  ti.  liitViiiir  I  in  liiinitcd  Imni'.  7.  Il.iid  pnlaii'.  s.  Toii;.'iir.  ;i. 
Middle  incatiis.  Id.  Inlriiin  nuiiiii-.  'I'luiii  I'riiiiiu-r',  .\ii;it(iiiiii;il 
-Mii-cmn.    I  'iii\(  i-ii  \    ot    rniniilc.  i 


§ 


i' 


ill: 


I- 


M^      ■;*: 


t'liKoNK    i)isi:\>i:  ()!•  Tin;  anitm  \i   ov  iiinininKi: 


|ti.. 


Ill'   nil.--   Mccdiiic.-.  aiisnrhcd   nnd    the   crili 


('\;linilllllii)ll    of   tln'   .-illlir   ill    lllc    pl'i'-rllt    tiliif    |il'ii\c>    il    t(i    lie    llolliill;,' 

liiit  ;i  iiiji.-.-  (if  rascdiis  iiiallir,  coihimim'iI  oT  cell  di'lriln^  ainl  p"ly- 
iiiiclfiir   li'iicncylfs.      C.-iM's   occii.-idiiiilly   (U'ciir   in    uliirli    ihc   lliiid    nf 

iliir  clciiH'iit-  iiiiilrri.fi)  lally 
(l(',t;t'iU'ratioii.  'I'his  is  llic  casi'oiis  lonii  of  the  iliscasc.  and  it  is  ai'- 
cniiipaiiicil  liy  niiiiu'riiiis  liactci'ia.  -iicli  as  .-laphylocucciis  iiyouciii-' 
iiiul  soiiH't  iiiii's  Asiirriiilliis  fuiiiinnl iix. 

Siiiiictiini'.-  ill  ailvaiiccd  ca.-cs  the  |icri(isl('iiiii  liccniiu's  uiiiisiially 
jn-tivi",  and  little  jiittin.iis  and  >|M(iil;r  of  lunic  will  m'nw  ami  prnjccl 
out  into  the  aiitnd  cavity,  rvni  in  rare  casos  hridjiiiii;-  it  aiToss  and 
\)\  riiniuilioii  (d'  tlii'ir  laniclla'  ilividinjj;  it  into  scdidiis.  In  raii' 
cjisi's.  also,  cysts  J'orni  hy  (lislcnsion  nj'  lynipli-spaccs  or  ducts  williin 
the  antniiii  ( l''i,i;'.  liS). 

Etiology. — The  iiid  tradition  liandcd  down  fur  jicncral  ii)ii>,  that 
decayed  tcetli  were  the  u>ual  cause  of  antral  einpyeina.  is  advocated 
liy  Moldeiiliaur.  I''racnkei,  IJeverly  lioi)iiis()ii,  and  others,  while  Ziicker- 
]\aiidi,  Chatellier,  Demochowski,  ScliiU'ers,  etc.,  helieve  in  it-  intra- 
nasal oriffin  in  a  lartre  majority  of  cases;  and  this  accords  lar;rely 
with  my  own  t'.\|)erience.  iJosworth  doubts  the  prohahility  (d'  actual 
extension  of  tlie  disease  from  the  nasal  fossa  into  the  maxillary  sinus, 
but  is  of  the  o])inion  that  the  majority  of  cases  arise  (1)  from 
closure  of  the  ostium  from  pressure  (d'  nasal  ])oly])i,  ('I)  from  pressure 
of  cnlarjzed  middle  turbinateds,  and  (;5)  from  extension  of  disease 
from  I'arious  teeth;  while  N'yles  is  of  the  opinion  that  the  iio~c  and 
teeth  are  abont  eijual  as  causal  factors  in  ,i,Mave  forms  of  the  disease. 

M.  Saint  llilaire  reports  two  cases  (■lininuil  nf  fjirjituidlniiji, 
Auiiust,  LSitS)  of  enii)yenia  of  the  antrum  (d'  Iliiihmore  cau.-ed  by 
plu^'irinii'  (he  nasal  fossa'.  One  occurred  in  a  lady,  au'ed  .")'.',  who  had 
l)eeii  sulferini;'  from  alliumiiiuria  for  two  years.  To  check  a  severe 
attack  (d'  epistaxis  liello((|'s  cannula  was  nsed,  jiluir^inj:  the  anterior 
and  posterior  ends  (d'  the  pa.-sa,i:e.  In  two  days  severe  pain  occurred 
ill  the  suborbital  region.  The  anterior  pliii:'  was  removed  and  two 
days  later  the  posterior  one  also,  hut  the  aiitnim  was  full  id'  pus. 
And  three  months  later  operation   for  its   relitd'  wa-  performed. 


The  other  was  in  a  woman  of  ;!!•.     The  iiost 


I'll  wa.- 


l)luj:<i'ed  to 


cluck  violent  cjiistaxis.  This,  owini:  to  similar  pain  as  that  of  the 
first  .-ase,  was  removed  two  days  later.  Pain  and  (edema  disajjpeared, 
but  in  a  few  days  the  antrum  filled  with  pus,  which  conld  be  seen 
in  the  middle  meatus. 

Symptomatology. — Tf  tlie  disease  is  caused  by  inflammatory  ac- 


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IMAGE  EVALUATION 
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Photographic 

Sciences 
Corporation 


23  WEST  MAIN  STREET 

WEBSTER,  N.Y.  14580 

(716)  872-4S03 


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l)isi;.\si;s  (IF  Tin;  \.\s.\[,  i'.\ss.\(ii;s. 


iioii  ;iii(l  x'tTclioii  (if  jnis  iiidiicifl  liv  clnsiirc  nf  tlio  ostium,  the  cavity 
will  in  time  Ix'i'oiiiL'  i'lill,  and  pain  from  tlie  prossurc  of  retained 
secretions  will  resull.  WIk  n  it  arises  from  caries  of  the  teetli,  i\w 
ostiiNii  not  liciriLi  closed,  the  dischar.L'e  c.-ca|ies  tliron;_'h  the  outlet 
and  piiin  docs  tupI  Ikiiuiic  .-d  curly  or  |iii>ininiiit  a  ^\nl|•tom.  In 
either  case,  however,  tlie  Jaw  may  he  tender  on  pressure,  and  the 
teeth  on  the  all'eeted  side  may  have  a  fullness  and  soreness  on 
closinjr.  Sooner  or  later  fietid.  creamy-C(dored  disehar;:e  makes  its 
escape,  and  flows  from  the  no.-lril.  The  odor,  oiie-sidednoss,  and 
r(dor  are  chari.i  Icri-t  ic  <d'  >inu<  disea>e.  'Ihc  jidjnt  i-  to  asceiMain 
positively  the  source  of  its  origin. 

Diagnosis. — The  dia.irtm^is  of  antral  disease  is  fre<iuenlly  oI)scnre, 
aiul  conseiitu'ntly  a  po.-ilive  ci>iicIu-ion  can  randy  he  arrived  at  upon 
the  lirst  examination.  The  pnxnce  in  (uie  nasal  cavity  of  pus  of  a 
creamy  color,  and  posses-ini:'  an  unpleasaidly  aromatic  odor,  while 
the  other  nasal  cavity  is  free,  is  always  suilicicnt  to  indieat(!  tluit 
suppurati\c  discas(>  exists  in  otic  or  other  of  the  accessory  siinises. 

'I'he  (lUistion  is  whrlher  the  disease  is  frontal,  ethmoidal,  antral, 
or  sphenoidal":'  Sometimes,  too.  the  muco-purulent  dischar;ie  pro- 
duced hy  the  picsciice  of  tia^jd  polypi,  associated  with  alro|ihic  dis- 
ease, simulates  thi'  pu*  of  :inlral  -uppuration.  l''oreii^ii  i)odies  aiul 
rliinoliths  may  also  ;:ive  ri-e  to  a  sonu'what  similar  discliarL'e. 

Alter  cleaiHiiii:  the  nostril  the  application  of  cocaine  to  the 
mucous  niendirane  should  malerially  aid  iti  diatrnosis. 

Its  astrin<j;ent  action  upon  the  tissues  will  make  the  presence  or 
nhsonce  of  polypi  (citain.  The  same  may  he  said  of  forei,<rn  hodies. 
These  heintr  excluded,  ihe  next  (piotion  is:  which  sinus  is  atrected? 
After  thorou^ih  clvausin^^  and  shrinka,i;e,  the  presence  of  a  drop  of 
creamy  ]>us  in  the  middle  meatus,  just  exiermd  to  the  lower  border 
nf  the  middle  turhinalid.  is  jilnio>(  of  diaj.Mie.stic  value,  if  the  pus 
is  farther  hack  and  vi>ihle  in  the  posterior  nares.  it  may  have  e()Mie 
from  the  diseased  sphenoid  sinus.  If  farther  forward  in  the  vicinity 
of  the  infundihulum.  from  the  ethmoid  cells  or  frontal  sinus;  hut 
in  both  the  latter  the  tissues  of  the  orbit  would  be  likely  to  be 
alfected.  This  rar(  ly  occurs  in  simple  antral  disease.  When  the 
(pinntity  of  pus  is  hirne.  even  after  (leansinir,  whatever  its  ori^nn,  it 
may  extciul  to  all  these  locations,  and  the  diai:nosis  becomes  more 
dinicidt.  S(unetinHN  by  bcndinj.'  Ihc^  head  forward,  the  exit  of  the 
pus  from  the  ostium  niny  bo  verilied  by  examination  with  the  nasal 
speculum  inmu'diately  afterward. 


CIIUOMt'    ItlSKASi:    ()!■■     Illi:    ANIlil  \I    OK    11  ICll  Molil 


Hi: 


Tlio  iit'iiriil;:iiis  wliidi  nriM'  I'rniii  siiiii.-iti>.  uliiMx-vcr  luciititl.  arc 
not  of  imicli  (liiiiiiio^li  \jiliir.  Si  ill.  tlicrc  is  nil  iiiironit'nrtjil)l(!  fi'ol- 
injz.  ii  <(ii>itivciirss  (111  prcssiiif.  iiml  ;i  liiHliiiir-»  nf  \\\i-  ull'cctt'il  jaw 
ill  clo.-iiiLr  the  ti'i'lli,  any  (if  wliicli  iii.iy  lie  (aiii-cd  Ky  aiilial  disease, 
but  imt  l»y  sii|t|nii'ati(m  of  iIk'  dllicr  .-iiiiisi's. 

Mdicaii  lli'dwii  izixcs  line  .-iun  in  (l;;iuii(i-i-  wliidi  in  my  cNperi- 
eiuc  ha>  liccii  (if  liltlc  value  lie  >ay-  llial  after  elean-iii;:  llie  pus 
away  liy  a  |ile(l;:ei  df  enMnii.  |ire«siire  iipdii  llic  f;iii;il  Willi  (if  tlie 
niaxillary  siiiiN  will    pi'd.liiee   its  reiipiieiirniiee.     'I'iic  iiiii\illary  Iioiie 

seemed    lo    lie    Ulli  llll  llelleed    liy    .-Iliy    preS-Ulc    which    il    'I'cmed    safe    to 
make 

1  iriijatidM  i-  aNd  I'eedmineiidi  d  ;i-  nii  ;iid  Id  (li;i'_'iidsis.  'I'liaf  i.-. 
liy  jiassiiitr  the  pdinl  (if  a  l\iisiaehiaii  ealhet(  r  atlaelied  to  a  svriii,L:i' 
ilitd   the  (i^lium   and    w;i-hiiiLr  dUt    llie   (:i\ilv    with    unrm    w;iter;     the 


M 


1"\<S.  ti7.      I'lliil  lie   illiiiiiiliiitiiv  with   llivililc  -liiiiil<  :iiiil   (  nrd-;. 

pus  disciiarLicd  wmild  iiidieale  the  presence  df  the  diseii.-e.  It  may, 
liowever,  lio  remarked  that  when  the  [lassa^fo  is  suiriciently  upcn  Id 
admit  tlie  ininidiiction  of  tlie  catheter  th(>  pus  can  usmilly  lie  seen 
issuing'   frdiii   the  ostium  without    the  use  of  the  iiislrumeiit. 

I'lxpldratdiy  puncture  as  ji  mithid  of  dini^uo-is  lias  alwavs  re- 
ceived a  certain  amount  df  favor.  It  i-  made  either  throuirli  the  in- 
ferior meatus,  the  canine  fo><a.  or  the  oral  (a\ity.  hciween  the  second 
l)iciis|iid  and  tli;'  first  molai'  teeth,  and  iniernal  to  tin  in.  With  at! 
the  pre-cut  iuean>  of  exploi'Mt  idii  at  cdiiimaud.  it  isdoulilfnl  whether 
puncture  will  ever  he  freipieiiily  re(|iiire(i  in  the  future,  ('hiari,  in 
givinj:  tli(>  history  of  mu'  hundred  cases,  says  that  the  rhimiscopie 
(wamination  ,i;ave  ^uch  e\eelleiit  diaLrimstic  results  that  lio  nnlv  rc- 
(piired  to  piincturo  fiuirtccn  times  throiifih  the  inferior  meatus,  to 
iIl^urc  a  correct  dia,LMinsis. 

Of    all    the    aids    to    diagnosis,    prohahly    transillumination,    hy 


'iff 


'!  ! 


108 


m^i.  \-i>  (ir    riii;   \  \>  \i,   r  \>>  \<;i>. 


!( 


plilcillLl  il  ^llilldnl  rlccll'lc  hiMI|)  ill  the  liiuk  |iilll  (il  lllr  i|(i-ril  llliilllh. 
illl  I(Pi|llc(  (I    li_V    \'n|tti|illi,    >t;lllil-    the    lil>l    (l''i;^.    (11).       A  1 1  lu  Ulu  II    nl     IIM- 

<l(iiilili'il  Viiliic.  llic  ,'iiiii'iini  <i|'  \v('iL:lil  iitlai'lird  |n  ii  li\  ililVcrciii 
rliiii(i|iii:i>i.-  \iirir-  ,cr\  i:ir,iil\.  (;niiL;iii  nhciiii  >ii\-  ilini  i  iiiii-;lliiiiii- 
ri;i!ii(n  i«  (ificii  i'iiili;iriii->iiiL:.  <>n  ii.«iiiLf  it  lie  luis  rmiinl  \\  rll-iiiiiikid 
>iilHirliiiiil  iiiiilii'ii.  imliial  iiiL:  \n\-.  iiml  ii|>i>n  n|ii'iiiii,u  tlir  aiilniin  I'hiiikI 
liiinc — llif  iliirkciiinL:  ln'iiiu  raii-cil  liv  a  tliickciii'd  iiiih o-a.  tiiaiil. 
"Ill  ilic  nilicr  liaiid.  think-  it  iiiav  iil'tfii  lie  ii-criil  in  a  iic,uati\('  wav. 
Ill  .-f\cral  >ii>|ii(inii>  cax'-,  uhcrc  piN  ua.-  Iifluvi'il  to  lie  |irfsciit.  In- 
I'niinil  Kii  t  rair-illiiiiiiiiat  inii  tlir  lian-liH'ciii'V  mi  clrar  that  ciiiiivciiia 
dl'   the  >imi,-  ((Uild    he   |iii-il  i\cly   (Acliiih'd, 

These  are  iiiily  e\ee|p|i(m^.  hnwcver;  as  a  rule,  the  ii.-c  n\'  ilie 
eleelrie  hiiiiji  ill  the  iiKUith  will  |ir(>diiee  an  iiiiilira.  nl'  nmre  ur  less 
ileM>it_v  heiieatli  tlu'  jnwcr  eyelid  in  each  ease  (d  antral  disease. 
Milli^an  tells  ns  he  use.-  NdllnliniV  lain|i  in  every  sir-peeted  ease:  and 
wherever  it  Tailed  to  iinidiiee  a  li.izht  z<ine  lieiieath  the  eytdid.  and  u 
led  and  liiiniiKiii.-  |iii|iil.  on  ii|ienin,u  the  aiilnini  pus  had  hi'en   loiind. 

(Ireville  Maediinald  lay.-  ;:reat  stress  cm  the  iael  that  where  we 
have  -ii|t|iiirati()ii  with  ;.M'aiiiilatinn-ii.-siie  ur  |>idy|ii  in  llie  middle 
meatus,  we  can  stddnm  Ite  sure  id'  the  extent  or  severity  nl'  the  disease. 
He  says  he  lia>  Ireiplelltly  seen  ease-  when  the  siippiiratinn  nl'  the 
antrum  was  siippd.-ed  in  Ke  the  whole  tmnlile.  Iiiit  in  wliicii  it  was 
afterward  proved  that  the  Imnial  sinus  ami  etlinmid  cells  were  Jiisl 
as  seri()n>ly  involved,  while,  on  the  other  hand,  eases  which  had  lonji 
lieeii  treated  lor  so-called  neerosiii":'  ethmoiditis  turned  o\il  to  he 
overlooked  cases  of  profuse  antral  siippuration. 

My  own  iiio.-t  recent  ea,-e  was  u['  this  doiilile  nature.  I  at  first 
took  it  1o  he  pure  ethmoid  di-ease.  as  there  was  piofu-e  granulation 
and  snppiiratioii  of  the  po>terior  ethmoid  cells,  accompanied  hy  deep- 
.-eated  pain  in  the  eye  of  thai  <ide.  (iahaiiocaiitery  operation  of  the 
hyperplasia  and  ciirettajre  of  the  cell-  failed  to  check  the  discharire. 
'riien  I  discovered  that  the  correspoiidim:  antrum  was  involved. 
l{eino\al  of  a  molar  tooth,  perforation  of  the  aheidus.  and  daily  wasli- 
iiijrout  with  hot  hoileil  water  in  a  few  weeks,  toiicther  with  the  previous 
treatment,  reinoxcil  the  whole  of  the  do'dile  disease. 

For  several  years  I  have  u>i'i\  transillumination  l»y  the  electric 
lamp  in  all  cases  where  I  su.-|»ected  antral  suppuration;  hut  I  cannot 
say  that  the  result  has  lieeii  suMiciently  marki'd  to  make  the  diaij;nosis 
jiositivc  liy  it  alone  in  a  sinjrle  ease.  I  have  not  opened  an  antrum 
without  findin<r  pus:    Imt  still  the  umhra  from  illumination  was  not 


CIIHONIC    IMSKASK    (»l'     llli;    ANIIUM    (»!'    II K;  llMOlii:. 


HI!) 


«li'cicli'(l  I'lioiij;!).  even  with  tlic  (liirkciicd  |iii|)il  iidilcil.  to  justify  iiii 
<>|H'nili<iii  uitluiiit  llic  iMfsciicc  nl'  dllicr  ciiinilly  ]Mi.--itivo  si^ns. 

Prognosis.  'I  ln>c  ciiscs  iiivolvf  iilllc  iliin.^cr  to  lilV;  vet  s|)nti- 
laiK'dii.-  ic((i\ory  Jinm  cliroiiic  sii|'|iiirati(iii  of  the  iuitniin  rarely,  if 
<'ver.  ocfii'-s.  I>y  (arcliil  ami  |)ci'.-i.-iriit  in-ai  iiniil,  liowcvfr,  all  cast-s 
■  :iii  |pc  i('li('\('(l.  ami   many  nl   tliciii  ciirrd. 

Treatmen'.  r.n-uorili  icll-  n.-:  ••'I'lir  (■>-(iilial  rcaliiir  nl'  tin- 
trcatiiit'iit  (if  a  ca.-i'  nf  >ii|i|iiiialivc  di^ra-r  of  the  aiitiiiiii  cmisists  in 
(i|iciiiii^'  (lie  lavity  fur  jpihimi-  di'aiiiauc,  ami  -iili-ti|iiriiily  its  thiiinii,i,'h 
<li'aiisiii<r  and   disinlVciidii." 

In  ill''  lalit-r  clan-c  all  rliimi|n::i.<is  ai^rrc  'I'liry  aurt'c  also  in 
llic  foriiicr.  while  tliey  dill'i  r  w  idrly  in  ilicir  methods  of  |iroeeduri'. 
Still,  they  iiniliilly  aeee|il  a-  im|'erali\e  the  k  nio\al  of  any  polypi, 
^liiannlal  ion-I  i.-:-iie.  ni  h_\  |icrl  io|i|i\  nf  the  middlr  1  iirhinated  which 
jniiiht   he  oli-l  lUel  in::  the  o-nnni  mavillaie. 

The  diri'il  inalmiiii  d  iIh'  -ii|ipiiralion  may  he  <ondneted  in 
one  or  other  of  the  fojlouin.u  way.-:  — 

1.  \'t\  direct  iniLialion  ihion^h  the  ostium.  (Ja\il.  of  Lyons,  is 
the  v:vv:\t  apo.-lle  n\'  \\\\<  incthod  ttf  treatment,  lie  claims  that  it 
lan  he  aecompli>hed  in  a  laiLic  majority  of  cases,  and  that  the  anirnm 
can  he  washed  onl  icniilarly  and  ((iinpletely  without  any  arlilieial 
opening;'  \\liate\er.  nui  of  II  caM'.-  he  >iiceeedeil  hy  tlii-  method  in 
t.'^.  or  (>'■''  '/.,  pel'  cent.;  and  "iil  id'  lhe.«e  had  to  I'esorl  to  other  treat- 
ment in  only  (i  la-i  .-.  'The  larger  niimher  were  cured  in  a  ,>hori  time. 
The  thiid  iwed  \\a.-  u.-ually  a  warm  >M|uliim  (d'  horic  acid.  The  in- 
."-trumcnl  \\>rt\  was  a  I  leryuL;  catheler,  lll^e|■tl•d.  willi  tin  point  turned 
downward,  hetueeii  the  middle  tnrhinatrd  and  the  mit-ide  wall. 
l'a.->iiiL''  the  in^Irunieiit  upward  to  a  positi'^  ai'o\c  the  ostium,  he 
turns  tlii^  ]ioiiit  outward  and  ;;ently  cn^aLics  it  ii  the  uiMiitli  of  ilu! 
cavity.  This  icipiire-  careful  manijiulalion,  as  \\  ■  pmnl  of  tiie  in- 
stnnnent  is  in  clo.-^e   jiioximilv   to  the  orhit. 

At  the  llr-t  washiiiL:  tlu'  li.-chap^e  is  puiuieiil.  fcetid.  and  sonie- 
tinu'S  ciiseons:  hut  htdiuc  the  irrii;ation  is  over  the  lliiid  returns  from 
the  naris  jierfectly  clear.  On  each  HUcceediii;^-  wa>hinu'  the  pus  dc- 
ci'easos  in  quantity.  After  a  few  washinirs  notliini:  comes  away  hut 
a  mass  nf  ffclatinon.s  innco-)ui>,  the  water  itself  lieini^  (piile  clear. 
At  caoli  gittini,'  llio  mass  dischar^^ed  liecimies  smaller  and  finally 
ceasi's,  tlic  patient  hcin^  cured. 

2.  By  openin,!,'  throuLdi  the  inferior  meatus,  or  Jourdain's 
method.     Of  this  plan  Oundas  tjrant  is  a  vimt  stronu'  supporter.     Mo 


K(» 


J»lSi;.\>l>    »tl      llli;    NASA  I,    I'ASSAOKS. 


clllilllS    lluit     il-     lllf    lllltllllll     rnliillUlllicilto     willl     the     I't'Spi  niloIV     I'ilS" 

sii;T(.fi^  jiimI  Hot  tlic  (lijjTstivc,  llic  more  iiiilunil  (iiK'niiij^  will  ho  liy  thu 
iiiisc.  A  Iter  Mpplviiij,' a  l.">-|i('r-cciil.  MiliiliiPii  nf  curniiic  Id  tin'  iiiiicniis 
riiciiiliriiiir.  he  uses  J\riUiM'"s  truiiir  ,iml  ciiniiiil;!.  )i('iu'tnitin<(  llu; 
Jiritriiiii  tlifoii^li  the  wiiil  ol'  tlii'  iiilVrinr  iiifiitiis.  \Villi(liinvin^f  lli<' 
trocar  and  Iraviiiir  tiic  (imimla  in  kIIii.  lie  attailics  it  to  the  |i(iiiit  ..|' 
till,'  >viiii,ii('.  ami  waslirs  oul  llir  cavity  wiili  warm  solution  nf  l)oric 
acid,  llic  lliiiil  c>ca|piii,L;  lliroiit;li  tli''  natural  opening.  After  cacli 
'rcalnicnt  llic  cannula  i^  rcnio\cd.  At  the  uoxt  sitting'  (•oeaiiit!  is 
a<:aiii  a|)]dicd,  the  cannula  rcin>crtcd,  aiul  the  trcatiiienl  repealed, 

(irant  claims  that,  althonjih  the  treatiiu'iit  is  somewhat  diiliciilt, 
Vet  the  nunilicr  of  irrij^atimis  rcipiirid.  hein^  los  than  l»y  other 
meth'ids,  will  justify   it.-   ii.-e. 

/('im,  of  haiit/.ic,  criticizes  this  nicllmd  .-e\crrly.  'I'lic  dilTioiilty 
of  operatin;^  in  this  re-fion,  the  tliicknc.--  of  the  naso-antral  wall  in 
many  cases,  inellicieney  in  diaina^ic.  ami  the  impossihility  of  personal 
irri^Mtioii  Ky  the  patient  are  amoiijr  the  points  which  he  emjiluisizes; 
and  to  these  miLilit  he  added  the  evil  ciVccts  of  successive  a])plications 
of  cocaine. 

;{.  i'>y  removing'  a  nudar  tooth  aiul  openin.ir  the  antrum  tlirouiih 
the  alvc(du.~.  This  is  ('oo|ier's  wcll-kiuiwn  method,  and  is  warndy 
supported  hy  Zeim,  Harrison,  .Milli<:an,  and  Hoswortli. 

When  the  teeth  are  sound,  Zeim  condemns  renuival,  and  sii<igesls 
porforatin^'^  the  antrum  throufrh  the  roof  of  the  mouth  in  rlo.se  prox- 
imity to  the  teeth,  cither  hetween  the  second  hiciispid  and  tlic  first 
molar  or  hetween  the  lir.-t  and  secoml  molars,  'i'he  fact  that  tin' 
opening:  into  the  alveolus,  or  floor  of  the  antrum,  and  the  ostium 
ma.xillare  are  at  opposite  etui-  (d'  the  same  cavity,  must  l)e  conceded  as 
an  advantafio  in  irripition.  while  the  facility  it  alFords  for  personal 
treatment   is  also   in   its  favor. 

To  kee|i  the  artificial  openinj:  clear,  various  silver  and  gold  tubes 
have  h;M'n  devised  for  permanent  insertion,  during  the  period  re- 
quired for  treatment.  Tli(>  tnhes  are  attached  hy  silver  wire  to  the- 
adjacent  teeth,  and  plugged  to  prevent  the  entrance  of  food. 

Tn  many  instances,  however,  when  the  treatment  rc(|uircd  is  of 
limited  duration,  these  tidies  can  he  entirely  dispensed  with,  as,  with 
ordinary  care,  there  is  little  if  any  danger  of  the  food  passing  through 
the  opening  into  the  antrum. 

4.  Desault's  plan  of  opening  the  canine  fossa  appears  to  bo 
steadily  gaining  ground.     Tt  is  claimed  that  tlio  patient  can  treat 


<iii{(iMc  him'.am;  m'    iiii:    \\ii;i\i   ni    iikmimoi;! 


1:1 


liiiiiM'lr  rtpiallv  ucll  in  tin.-  Wiiv  a.-  llirmi::!!  llic  iil\  culii-.  an.l  ilial  it 
will  frctjiu'iitly  |iic\riii  the  sacrilicf  dj'  n  -muikI  inotli.  A  tiilic  with 
11  phitc  attached  tn  lit  airniii-t  tin'  jaw  can  lie  iriaiind,  cvi'ii  licttrr 
tliiiii  ill  till'  alvcnlu-.  and  witlmiit   uirin;,'.     l'liij:^in,u  tlic  tiilx'  i.s  nn- 

ii(H'c.->a!'V,    as    lliric    i-    pract  iiallv    \\n    (lan;:iT   id'    I' 1    ('iitri'iii;^    tlir 

uiitniiM. 

Sonio  (tpcraturs  liavf  invadid  lln'  lanino  I'ns-a  \ri\  cxtciirivclv; 
and  witliniit  lu'^ilatiiMi  cliisrlcd  away  iiioii^^li  id'  tlic  iMrnial  aiitial 
wall  to  adinit  nf  digital  rxploriiliuii  >>(  thf  caviiy.  Tin'  aiitniin  is 
tlu'ii  ciirrtti'd  and  uaslivd  out  iind  |».i('ki'd  with  indnl'min  nanzc  'I'his 
is  cliaiiircd  i'('i;iilarly,  lln'  cavity  lirini;  krjit  ii|ii'ii  nntil  llinmimli  Inal- 
iiifi  takes  place.  Altlnmirli  rcvivrd  nirnily,  llii-  plan  id'  trcatnicnl  i- 
lint  iirw,  I'nr  wc  read  of  la  Mmicr  as  early  as  IT'in  treatini;  a  i  a.-e 
i«iicccssriilly   in   tins  way. 

.").  The  Ifoliertsoii  method  of  cnmltiniiif;  the  chii-elinir  of  the 
canine  fossa  with  the  jierforation  of  the  inferior  meatus,  in  mie  or  two 
places,  has  also  a  niimhcr  of  supporters.  Scaiies  Spicer  favors  this 
plan  (d'  tre.'itment,  as  the  mily  mie  -eciirini;  thoioimh  and  ell'eiinal 
tlraiiiiiffo  in  many  of  the  mo-t  dilliciill  cases.  lie  makes  a  lariic  o|icn- 
iiiLT  in  hotli  the  anterior  and  internal  sides  of  the  aiitriim.  These 
o|)enin;;s  lire  intended  to  he  permanent.  He  then  irriir.ite-  tlioron;:hly 
with  lioric  solution,  and  follows  this  hy  paid<in^'  the  cavity  liirlitly 
with  creolin  j^^auze.  This  is  left  in  for  forty-ei<r|it  hours  and  I  lien 
removed.  Xo  form  of  tuhiijie  or  mechanical  drainaLre  is  used,  hut  the 
cavity  is  syringed  out  daily  with  a  similar  waiin  solntidn.  '{'he 
patient  is  directed  10  hlow  out  the  cavity  fretpiciitly.  from  the  iiu-r 
to  the  month,  and  also  from  the  mouth  to  the  nose,  lie  claims  rapid 
Iioaling,  and,  although  the  perforations  contract,  tlu'y  usually  remain 
permanently  open  to  some  slijrlit  extent,  without  inconvenience  to 
the  patient. 

This  multitude  of  methiMls  all  jiractitM'd  to-day  hy  leadiiiii 
rliinolo<:ists.  oaeli  preferring  his  own  s])ecial  plan  as  the  hest,  hut 
ntilizin<i  somi'  other  method  in  exceptional  cases,  seems  to  prove  that 
the  results  are  not,  on  the  whole,  as  satisfactory  as  wc  would  like  them 
to  1)0.  A  few  eases  are  cured  (piickly.  Others  take  a  lontrer  time. 
All  are  relieved;  Init  in  many  cases  the  treat ment  re(inires  to  he 
carefully,  systematically,  and  persistently  followed  out,  and  tliat  for 
a  considerahle  time  in  order  to  pecure  a  perfect  cure. 

Tt  is  nndonhtodly  true  that  manv  cases  of  antral  disease  come 
under  the  domain  of  the  dentist  for  treatment,  and  manv  dentists 


.■■  1: 


^<>'l 


If   ' 


172 


DISKASKS    OF    THK    NASAL    TASSACIKS. 


cliiim  to  Im'  piirticiiliirly  sii'ci'ssrul  in  (li'iiliiifj  witli  tlit'so  rn?o>.  ]\\\t 
lliis  is  lint  ti)  i)f  woiidtTi'd  ill  Tlie  cases  tiiut  ((iiiic  iiaturallv  iindi'r 
their  chiir^M'  arc  tlmsc  of  denial  ()ri;;in,  the  reginn  id'  the  osiium  not 
hciiig  at  all  alVcctcd.  And  wIkh  the  carious  tontli  is  rciiiovc(l.  iho 
imtnini  luTloralcd  thron^rli  \\<  alveolus,  and  the  cavity  antiseptically 
washed  out  i'or  a  I'cw  times,  it  is  natural  I'or  the  linini:  nicnihrano  to 
heal.  An  entirely  dill'erent  state  of  tliinirs  e.\i-i-  when  the  I'liotogy 
is  nasal:  ami  il  is  this  class  id'  cases  thai  ii.-iially  Fall  into  the  hands 
of   the   iliinoldiii.-t    to   deal    with. 

In  my  own  |ira(iice  the  lar^e  majniity  ef  my  cases  ha\e  heeii 
treated  through  the  aKcnjiis.  .\illi(PUL;h  in  >e\eral  t>\'  \  hese  it  [in)k  many 
months  of  treatment,  yet  they  were  all  e\eiiliially  cured.  In  one 
case  the  treatment  wa-  (niilineil  to  wa-liin.Lr  out  the  nntiiim  thr(iu<rh 
the  o>liiim  maxillare  with  a  waiiii  suliilinn  (d'  resorciii  This  ca,-e 
healed  rapiilly  ami  without  return.  in  tliice  I  tried  perforation 
ihror.gh  the  canine  fossa  with  insertion  of  a  silver  tuhe  and  follnwed 
i)y  reirular  iri'iual  inn.  In  the  first  of  llie-e  it  was  siicces^fid.  In  the 
second  it  failecl.  lur  tliiee  years  the  patient  peisnnaily  cariicd  nn  the 
cleaiisinii'  treatment.  Imt  declined  to  lia\('  any  other  operative  treat- 
ment than  the  renewal  of  the  tulic  as  frei|Ucntly  as  the  njd  one  wni'e 
away,  in  the  third,  after  trial  for  weeks,  there  was  im  pro.-pect  of 
healing  in  the  antrum,  so  a  tooth  was  extracted,  and  a  week  or  two 
of  reiiular  iri'iijat  inu  with  Imt   hdiled  watei'  eirected  a  ciire. 

'I'iic  sci'otiil  III'  tlicsc  (■;iM>  is  wurtiiy  of  fiiitiiiT  ((iii^iiji'nil  imi.     'I'ln-  ]iiiti(iil 
Wiis  (if  a   I  iiluii  iil:ii-  liiTnily.  lliifc  liiii|liii»  and   his  innthii    liaxiii^r  diid  nf  jiiil 
inoiiiiry  t  iiIm  rciiln-is,     .\   few    iriuiillis  •.\<^i>,  a-  tiicir  scciiii'ii  In  In'  im  |iiiilialiility 
(if  ccssal  idli   (if  aiitial   (li--iiiarj.'('.   lie   linally   ( (iiisciitcd   td   iIk'   cNtrad  ion   (if  tlio 
lirst.  iiiiilar  Innlli.  and  jici  furat  imi  ilnniiuli  tiic  ahcdjiis. 

liisti'iid  (if  littiii^f  a  >i!\(r  tulii'  to  llie  (i|i(iiiiijr.  as  I  liad  dinii'  in  liis  case 
ill  till- caiiiiic  fossa.  !  in-tnich  d  liiiii  to  iiial<i' a  liardv-.ood  |ilu^'  to  lit  tlic  jiassif^e, 
tlic  lower  end  liciiii.'-  larirc  ciHniLrli  lo  iircxiiit  ils  s1i|i|iiiii,'  w  Imlly  into  llic 
aiitrmii.  'i'liis  |iian  I  liad  followed  mi  |iic\ioiis  occasions  in  tlic  trcatinciit  of 
other  cases  with  iiniforinly  ;.''ood  icsiilts.  Ilic  |ilnijr  Iniiiu'  rcinoMi!  each  lime 
irritfiilidii  was  rc(|nir!  d.  and  rc|ilaciil  ininicdialcly  atlcrward.  .Vt'lcr  a  few  days. 
as  tlio  jiaticiit  inana^'id  the  local  Ircatineiit  cjlicicntly.  the  anionnl  of  ims  at 
ilic  same  time  i;radually  diininishiiif,'  in  i|iianlity,  I  told  him  that  he  need  not 
return  to  I  he  oHicc  au'ain  for  a  iiunilicr  of  days,  lie  ict  iinicd.  Iiovv  ex  cr.  sooner 
lliaii  cxiKM-tcd  and,  with  a  distr»ssnl  c\|ii-cssi()ii  fif  face  infoiincd  me  that  the 
last  and  laifjest  pliiij  he  liad  used  had  (.'one  up  into  the  imtnini,  and  he  was 
afraid  that  the  jiivvious  eiie  had  slipped  in  also.  It  ajipeared  that  two  nights 
|irevi(iusly  he  had  fitted  the  ]diifr  into  the  alveolus  on  jroinjj  to  lied.  When  he 
involve  in  tlie  moniiiifj  it  was  (,'one.  lie  ]iasscd  a  pr.ilie  into  the  hole,  liut  could 
not  feel  it.     Thiiikin}.f  tliat  jiossilily   he  iiiiyht   have  swallowed  it,   ho  made  a 


i 


ciiuoMc  MisKAsi;  or  mi;    vsritrM  >>v  iiKiiiMoHi:. 


it:} 


lai'P'i'  iiiir  iiiul  |iusli<'il  it  in  ti;.'lill,\.  jftiT  wathin^  cuil  tlic  aiilrniii.  'I'lit-  iit'Xt 
I'Vciiiii)^'  it  wiiM  till  ri;.'lit.  Imt  w  In  i>  lir  iiwnkt'  in  llic  nimiiin^'  lir  could  juHt 
rcacli  it  with  liis  tniij^Mii',  and  an   lii>ni'  latfr  it   had  cnlinly  di«a|)|M  iirrd. 

On  ('.\aniiniiii;  tin*  antiiini  tlinin;;li  lli<-  ojirnin^s  with  the  |irnl)t'  I  Kiiihl 
nut  liinl  cither  ni'  the  fnii'i;.'n  lii>dic>(.  There  ■«cein<'i|  ti>  In-  an  almiidanre  ol 
space,   ami,    wj-hiii;.'   lhiiin;.'li    the  .aixenhis,    the    llnid    e<ia|ie(|    freely    fn'in    (he 


1'^ 


If 


l-'ig.  tiS.      CdlDlial   nceliiill   lit    the    niJ\illai\    -iini>,    the   -.nlijeel    of  ey-<tie 
disease,      a,    (';;nee!!n||s    ^|lael•s    in    liniiy    \\;\\\.       I),    I'ejriiin    (if    (lie    crirttil    tiir 
liiiiali<.     i\  (ilands  .if  na«al  |o»sa.     '/.  <;laiiiU  nf  the  niaxillaiy  sinus,     r.  l)e- 
fjenefatinj,' ^'land  ii>sue.     The  wavy  lines  aii.und  iiKJiiate  the  eapsule  of  the 
cyst.      (From   Lennox   Jtrowne,   IS'.iU.) 

nose  throiif^li  the  o-iinni  niasillare.  t  hi  lije  patient'-  a~-nranie  that  at  li'a>l 
one  of  the  ]iln;,'s  was  in  the  antrum  1  had  an  ana-thetie  ailniini-.t(red.  aiid. 
after  dissecting  hack  the  tissues,  with  liaininer  and  ehisij  .■nlai;.'eil  the  opening 
in  the  canine  fossa  (o  Hie  dianaler  of  a  cent  iinidre.     I'ihIci-  the  impression  that 


-. 


Kt 


i»i-«i.  \»i.>  Ml    I  III.  N  \>  \i,   r.\>.-«  \(.i>. 


Ilif    lor<'i;;ll    ImiiUi"*,    il'    tln'lr.    wkiiIiI    III'    nil     I  lie    tliior    of    tlir    ililtllllll.     I     is|>l"iii| 

■  lull.  ri';;ii>n  lii-l,  luit  roiijij  imi  liiitl  iiii\  lliiii;,'.  'riicii  I  |iM«-^nl  lln  Imi.]. 
IcWiinl  III)'  <i>>liiiiii  williniii  .11111-'-  Al'li'i'  liiii|i|iiii'.'  out  the  riixily  willi  ali 
t«oi'lM'iil  coltoti  I  ii^iiiii  |iii>-ii|  till'  tiiii'i|i><  n|iv\iiri|  and  IkkKw  mil.  'I'lii-  liiiii' 
fldtiiclliin^'  \\ii.'«  ■M'i/t'il.  till!  il  ii'i|iiiiri|  ,1  ^'ooil  ili'iil  i>l'  liMitjoii  Ik  ili'ioil;^!'  il, 
wlii'ii  oiil.  riiiiii'  II  |oiiM  iiinl  tliiik  |ihi;:.      \iiolliri'  iilii'iii|i|   \va>  iiiailc  in  llir  miimi' 

li';,'io||.  lojjowtil  li\  till'  lAll.litioll  o|  i\  .lill  i.llMri'  I, lie.  |  h|||i|>ii.|'  IIi.iI  ilflt'l' 
Hicy    \\rli'  rii;.M;.;i  il    uillilli   I  In    iii\il\,   wiiiili    wa-   llirirc.   I  lir    loiii     iil'  y  la  V  ilMl  imi. 

uiiili*  l\  in;;  on  llic  liaik.  to^ritliii  willi  ilic  iti-|>iriiioi  y  lone  in  lii''.il  hiii;; 
tliloii^'li  till-  o..liiiiii,  ii.iii  ilia.vn  ill)  111  ll|nMll'il  ullil  liai  kw  iil'il  In  III)'  l'<  vi"*l  **l 
wliiili  llii'\  hail  111  I  oiiM'  iiii|iai  II  il.  TId'  »iiiall)-l  iilii;;  «a>  luo  iiiil  iiini  n  «  in 
l)'n;:lli  ami  hall  a  ii'iil  inal  n-  in  )liaiii)'l)'i',  iId'  lai;,'i'i  mii'  >iiiii)'u  hal  thiikii.  and 
hall'  a   iriiiiinilD'  lon;:i'i .     'I'Id'v    wcri'  liolli   )if  tliciii   witlinnt    i  he  Imlj;)'  on  ihi' 

I'tlil    thai     I    had    olijilrd 

Cyst  (i|-   ihi;  Amim m. 

'I'\\<»  yiiils  jiuii  (liiiilo   II.   iMiiylil   wmt)'  a  coiiiiiri'lii'ii-^ivo  review 
111"  wliiit  wii'-  tlieii  kiinun  III  ilii-i  rare  di-ea.-ii'.  elosiiiL:  willi  the  ln.»tniy 

(if   il    la-e.       Hi.-    |ialielll    oillljilaineil    kI'    no    S_VIII|it(illl.-    e\ee|>t     tile    <|e- 

rnnnilv  III  ill)'  Irii  iiiaiai'  i'e::iiiii  ami  KJnoivu-laliia!  I'dM  caiL-eil  \i\  ilie 
|ire.».-iire  nf  the  Iniie'r.  On  iiiei-iiiL;-  Irei'lv  iiitn  the  eaiiiiie  I'li'-a  the 
liiiliy  uall  was  I'diiiDl  tn  he  aliiii)>t  e(im|iletelv  ah-oihcd.  Si\ty 
;.'raiiiiiie.<  nf  thin,  liiiliiil  lliiiil  were  drained  away:  ihi'  liiiinir  iiiem- 
hraiU'  uiidI  tn  he  i-l)i>ely  ailhereiil   (i>  the  Imiie.      hiirital  I'xaiiii- 

nalin  i(iS)'d    iintliiiiL;'  ahiioniial.      Al'ler  wa-hiiiL:    niii    ihi'    lavity 

and  |i,iikiiiL:  it  I'nr  three  da_\<  with  iiidnrdnii  uaiize  llie  reeii\eiy  and 
In'aliii;:  wer)'  iiiieviiit  I'nl.  A  year  later  there  wa>  no  reliirii  of  the  ey.«t. 
l,eiiiio\  liiowiie  .-ay.-  thai:  "Cy-tie  >iiiii,-ili.<  may  oriKiniite  in  two 
wa\>:  r>y  ili-teii-ion  (II  <d'  l\  iii|ph--|iaee>.  c.')  <d'  thi'  i:iaml-  aeiiii  or 
duets.  V\'j:.  (IS.  iiiiiii  a  pii'iiarat ion  hy  Alexander,  of  Uerlin,  )'N- 
i'in|ililies  a  eomlition  due  lo  the  lii -t-iiaini'd  eaii-e.  It  i.-  charaeter- 
izi'd  hy  e\ei'->i\e  laiiei'liatioii  uT  the  lione.  hy  di-ienih'd  KJand-duet.-i. 
siiliie  palehes  id'  rnuiid-eill  iiililt  rat  ioii.  and  a  ey-t-lik)'  iiielii^ion  of  a 
mass  of  ili-itsed  tdands  and  Idoml-vi-M  I-."' 


.■t 


^4 


(  i!.\i''n:ij  x.wiii 

i;illM<»||)   IHSKASK. 
<  ' A  I  AI.'lillAI.   illT''cti(iIl>    III'    llir   clllllliiiil    lr;.'iii|i.-    ;nr    imt    of    illfli'- 

i|ii('iil  iirciinciici':  iiml  in  iuiilr  i  km-,  vsIu  n  ili>  iii||;iimi'iI  tells  iirr  imt 
(idliiiliil   liv  till'  >uclliiii:  111'  tlif  -liirniiinliiiu    lui-al   iiiiiiDsi.  tlic  tli»- 

i;i>r  in;iy  «llli.»iilf  iim!  (li>;l|i|Hiir  Ultll  lllr  i:rlirl:ll  llrrllllt,'  III'  lllr 
ratiinlllll  rnilililimi.  W  llcll  lllc  (ills  lu'niiiii'  lilnrkcd  \i\  |i|i'»-urr 
I'liilll  witlliUlt  or  rinlii  rlllilliZiMHiit  111'  lllr  miiMIc  llllliilllllcd  Ii.m|\, 
lllf    illllilllH'ij    ciillililidll.-    lililV    IiiIm'   nil    >ll|i|ilir;ltiV('  llrtioli.   I'VcIl    IC-llh- 

iiii:    in    iHTiiistfiil    iilrrnu imi  iiml   flliiiiniil    in'rro^is. 

Pathology.-  -'I'll  Nnliinil   Miiikrii/ir  lu'lnn--  ihr  limiiir  nl'  lil'iiiiu' 

lllc     \fil     tllilt     SI)    lIcllM'lv    (ili-(Ulri|     nlir     klMW  Iriluc    ii|'     lllr     )iilt  lli*|i  i^'V 

111'  llii>  n\i:inii.  r.v  Jill  cMi'li-iM'  .-crirs  dl'  iiivc-t  ii;;il  imi-  lir  li;!-  ;ini\ril 
ill  the  (•(iMcliisioii  thill  tlif  Mi-nillcd  iiiVMUiiiitinis  (li';.MiU'r;iiii)ii  ol'  llir 
ctliiiiniil  is  imt  (III*'  to  niiicoiis  cliiiiiLri'  III  iill,  liiit  to  siMi|i|i'  iiilliiiii- 
matoiy  aclimi.  In  tlii.-  \ii\v  In'  i<  .-irnniily  .-ii|i|iiirtfil  liv  .Imiiit  lian 
\Vri,:;lil.  Ill'  liclicxrs  tliiil  iill  llic  ( liiini^i  -  rniiinl  in  ihr  iilmioiil  crll- 
ii'|irc-('iil  iiicri'ly  siic((s>ivi'  .-liii^rs  ol'  tin'  ,-aini'  all'i'ct  imr,  iiinl  thai 
tilt' re  lore  divisions  and  .-iilMlivisions  ol'  clliiiioidilis  tend  In  intrndiirr 
ill)  clcnu'iit  of  ciiiirii-iiin  into  our  |)iilliiilo;jiraI  ronci'iitinii  nf  tlu'  di>- 
oaso  ( l""i;;.  li!')- 

In  o|i[)iisitioii  to  ^\'llilk^^"s  idcii  tlnil  all  t!  hiiioiditis  is  of  tlir 
iialiiic  of  ncci'osi.-.  Miickcnzii'  .-ijilo  |)ii>ili\rly.  and  in  this  he  i- 
>ii|i|iorit'(l  liy  ll;ij(.'k.  I  hilt  |iiiiiilriit  ct  liiiioidit  i,-  may  ciiduir  for  Vfurs, 
without  iModiiciiii:'  any  lionc-lcsidn.  iiiiil  that,  ihcrcfori'.  llic  |iro|>o«i- 
lion  that  all  cllinioidilis  Inids  towiird  and  usually  dcvclojjs  into  niTfo- 
sis  has  no  I'oiindalioii  in  |iiitliii|oL:ical  fact.  That  it  diic>  so  occa.-ioii- 
idly.  however,  he  freely  admits. 

Two  other  I'iicts  he  dwell-  upon;  the  niic.  that  the  ethmoid 
re<rion  iilFords  ji  most  excellent  place  for  the  study  of  the  ori^riii  of 
the  so-cidled  nasiil  jiolypi;  the  other,  the  very  ^trikin^'  similarity  tluit* 
exists  lietween  the  yminji'  ;:ranulation-ti-siie  found  in  the  ethmoid 
rejrion  iind  the  structure  o  round-cell  siinoma.  iiiid  hence  the  possi- 
Iiilitv  of  error  in  din^jnnsis. 


iij 


..(*] 


176 


lUHKASKs  (ii    iiii:  \.\>\t,  r.\ssA(ii:s. 


MylcH  nccfiitiiatcH  tun  iitii>  utant  facts  in  iln  {intliulu^v  nf  ctli- 
inoiil  tliscnsc. 

1.  Ill  cxtrctiH'  pnlypnid  cast's  tlic  ctlimnid  is  rather  linttlc,  iitnl 
parts  laii  ca>il_v  !»■  iciiinMil. 

'J.  'i'lic  liniic  i.s  aliiKot  lliiitv  liai'il  in  sii|i|)iinitiv(.>  cases. 

'riic  )iatliol(ij.'y  of  ctlimoid  iiiid  aiilral  disease  reseiiiMes  each 
other  111  the  existence  of  sii|i|Mirative  |irn((«s  iiiid  in  the  sij.'iiiltcaiicc 
<»f  pro-lire  in  the  iiri;.'iii  id'  em  h. 

Etiology.     'I'he    uri;:!!!    i>i    the    disease    is    rret|Ueiiily    nl)«(iire. 


I''!;;,  111'.  I  Mlhniiiii:il  ion  "i  llir  (thiiniiil  rclK,  >liiiv\  in;;  ;;l;iiiil-  tu  i  i;,'lit 
(luitr  Tinrinnl  and  tlici>c  tu  lower  Irt't  liaml  intuc  or  Icsh  iiltci'i'il.  In  tli<' 
cxlirinc  lower  left  the  tini'ly  tilpiillatcd  ti>siie  i.s  a  t'aUe  iminlpiani'  eoin|io-iei| 
of  liyaiiiH'  tilirin   willi  a   few    pus  eelln.      ^.\fter.l.   .Nolaml   .Maikeii/ie.  i 


Xo<:h'cted  catiiii'Ii;il  iivoccs-cs  iiiiiy  pniiliice  pcniiaiieiit  hyper.eniia, 
risultitiL'  ill  retained  secretiniis.  witli  liiial  sii|ipiiraiive  actidii.  It  may 
SiIm>  arise  I'rnin  pressure  of  nasal  pnlyjii,  tlimioh  liy  many  writers  siiji- 
purafion  of  the  etlimoid  cells  is  hclieved  to  he  the  cause  of  polypoid 
disease.  Not  ini'reiiiicnt ly  the  cause  is  an  extension  of  the  .snppiira- 
ti\c  action  from  the  other  acces-^ory  cavities.  Accordinj^  to  Mylcs. 
l\vo-(liirds  (d'  the  eases  are  due  (o  tlii'  presence  of  polypi  in  the  region 


i:i iiMciin  iiisi;.\fK. 


i:r 


i<{  iIk'  ctliinoid  iciU.  vnIiiIi'  id  ntlu  r  iiiMiiix  •  s  ntropliic  rhinitiH  is 
-fniit'lijiifs  llu'  iiui.«f. 

< '(*ii«iitiitiiiiiiil  (U'liililv  iii'i.-iii;:  li'diii  tiilicK  r.lnsi-,  iiiiili|iniiiit  (lis- 
t  ii'i'.  or  »\|iliili-     iiiny  iiIj^o  lut  n-  ii  pirdispoHiii;:  iiui^c 

Symptomatology.-  rain  nt  iln-  nmi  kI  ilic  imsr  aixl  iti  llic 
iirliiliil  iiml  ttiiiporjil  rf;ii<iiis  i«  mir  n|  ihr  rnrln'cl  symptniiis.  TIiIh 
IS  ii»i'(iait(|  ii«iially  wiili  ili.-cliar^'r  nt  ni  iiiii-fnlorfd  \\\\<,  uf  a  iiuto 
iir  l(■^^  I'liiitl  iiilnr.  lriiiii  till'  iiJiii-  In  -miH'  t  a.»r«.  tiii'ir  is  prnnii- 
liciici'  i>v  liiil^'iiij:  al  till'  "iflc  <i|  till  iMiii  nf  ill.  iiM-f.  'I'liis,  liowovtT, 
is  not  frii|iii  nt  •  \rt  pt  a.-  a  it^mIi  ni  prosiiir  truin  p"l>pi  assncinti'd 
Willi  llif  riliiiiKjii  ili»(ii»f,  \\  lim  tlif  antfiinr  cclN.  wliiili  aif  twn  "r 
tliiti  in  nnnilMr  ami  >iliiatril  cxli'irial  In  llic  antiiinr  tnil  nl'  tlif 
mikIiIIc  liirliinali'il,  air  atl'Mtiil.  I'Mipjii'  ilnna  inav  Kr  pri'scnt  from 
prcsfiirc  npon  tlir  wall  nt  iln    oiIhi    m  ij  |ni>-inli!tration  may  ocrnr. 

tlirollL'll    pi'li'niatioli..    nj'    till     dllut;'!    platr    of    lllr    (' ll  IIH  ii<l.       With    tilt' 

|iii-t(iinr  cell.,  wliicli  an  ilu  -.,ni.  m  iii.,!ilii  r.  tlionL'li  Ioniser,  llif 
pain  i-  iini  .piitf  >o  scvtTi'. 

Diagnosis.  .M'tcr  rlcan-iHL'  tin  iia-al  pas<a^-c  liv  the  nM'  of  an 
alkaline  >pra_v.  am!  ^Iirinkiiij.'  tin'  tif;«-Me-  \>\  the  application  of  cocaine, 
all  niher  (liscjiscs  Iml  tlin>.r  uf  the  aices.-oiT  sinuses  slioiiM  he  easily 
•xeliidefl.  In  ili^tiiiL'iii^hiiiv  elnniohl  finin  antral  <li»ea-<  ihe  tliiont- 
lamp  shonlil  he  of  ;:reat  >ei\ice.  a.-  there  i-  lanly.  if  ever,  an  ninhra 
in  purely  ethmoid  all'eetions,  w  lierea>  in  siippnraiion  of  the  antrum 
it  is  n-iially  one  of  the  distin^ruishin;;  features.  Inirals  points  out 
that,  after  thorough  clran-iiiLr.  pus  from  the  antrum  may  he  imted 
trickling'  down  over  the  middle  of  the  inf.rior  tnrhiiiatcd,  while  in 
issnin;:  from  the  ethmoid  (dls  it  llows  over  the  posti'rior  end.  'I'Iil' 
deep-seated  pain  produced  hy  ethmoid  disease  is  also  of  diagiiostie 
\iilue.  ili>tinL'ni>hiiii:  ii  fnnn  antral,  in  which  this  symptom  is  usually 
wanting;.  'J'he  l)nl;:in^f  of  the  I'Vo  forwanl  iloes  not  occur  as  a  result 
of  (  ither  antral  or  -plunoid  di<:easp. 

Prognosis.-  -Simple  catarrhal  ethnioiditi-:  under^rnes  re^cduiion  in 
unison  with  tlu^  acute  rhinitis  to  which  it  owes  its  ori.L'in.  Woakes's 
necrosin<r  elhnioidiii>.  in  wliieli  varies  of  the  hone  exists,  is  a  much 
more  -erious  alVair.  and  little  likely  lo  re-iilt  in  ahsohite  euro.  Sup- 
piiiative  ethmoiditis,  occupyiiii:  a  niedmni  position  hetwcen  the  two, 
.-hoiild  he  ameiiahle  to  treatment,  and  ic-uli  in  enre  in  the  majority 
of  instanees. 

The  disease  is  imt  daiit'erous  to  life  unless  it  extends  to  the 
(M'anial  onvity.     More  fre(|ueiitly.  owinj:  to  the  thinness  nf  the  walls 


•Ii  '^ 


;■■•  'it 


1T8 


DISKASKS    OF    THE    NASA  I,    PASSAGKS. 


and  its  i)r().\iiiiit}'  to  the  ove,  the  (irbil  hfcoines  atri'cted,  soiuetiiiios 
resulting  in  ahocess.  Operative  treatment,  combined  with  thorough 
(•leansing  and  drainage,  is  often  prnduelive  oi'  godd  icsults. 

Treatment, — In  mild  cases,  unattended  hy  hyiiertrophy,  shrink- 
ing the  jiarts  with  cocaine,  and  J'oUowing  this  with  sprays  ol'  solu- 
tions of  either  l.")-volume  j)eroxide  of  liydrogen,  boric  acid,  or  resor- 
<  in,  should  relieve  the  disease  and  (juickly  result  in  cure. 

Any  of  the  al'ove  miLrht  be  used  as  follow-: — 


I.     H  reroxiilc  111 


In  III  ii<'cii    ( |o 


:\(liiiuii     ml  .SOI 


^r. 


■J.      H   Acid,   h.irir 2 

(ilyccriiii    4 

AfiUiiiii     at  ."U) 

.\r. 

:!.     H  Itc-inciii    1 

Ainiaiii     ad  30 

In  severe  eases  wlu  re  suppuration  exists  without  nccrosi.-,  oper- 
ative treatment  will  be  necessary.  Polyj)!,  if  present,  should  be  re- 
moved. Also  any  granulation-tissue  that  may  apjjcar  in  the  neighl)or- 
hood  of  the  cells.  This  may  bo  done  by  curetting  or  cauterization, 
and  will  clear  the  way  for  the  antiseptic  treatment  already  referred  to. 
Direct  opening  of  the  ethmoid  cells  above  the  middle  turbinated  is 
a  diilieult  operation.  V>y  removing  the  anterior  end  of  this  body  it 
ean  be  better  aeeomplished  and  the  anterior  ethmoid  cells  more  easily 
reached.  This  can  be  done  by  the  use  of  tlie  cold  snare,  curved  scis- 
sors, gouge,  cutting-forceps,  or  (Iriinwald's  fnrceps.  The  cells  can 
be  reached  by  gonge  and  curette.  '^I'he  main  features  after  operaMon 
are  antiseiitic  treatment  and  free  drainage.  The  ajiplication  of  lactic 
acid  is  sometimes  followed  by  the  best  residts.  (Jleitsmann  favors 
the  application  of  strong  solutions  of  nitrate  of  silver  in  many  of 


1.     R   rcroxiJe  of  liydinfri'ii   3ij. 

Aqiuim    ad  .^j. 

•2.     B  Acid,  boric prr.  xxx. 

(Myccrini Sj. 

Aquam    ad  .^j. 

.').     It   TJcsorcin    Rr.  xv. 

Aquam    ail  5j. 

M. 


KTIl.M(HI)    I»1M;a.-.K. 


ITii 


tlii'M.  CM,.,  a  cue  luMii-  ol.fainc.l  l.y  the  combined  siiru-i,,,!  aiul  lo.al 
iroatment  m  some  iiistaiuos  in  one  or  two  months.  Jle  al-o  1  ,v< 
stivss  on  the  importance  of  alhnvin-  the  reaction  of  one  curett..mcnt 
to  inu<s  ofT  before  another  i.s  accompli.she,]  in  cases  \Nh..ie  this  „|,er- 
iitioii  is  necessary. 

:^lvles  drills  or  gouges  an  opening  tliroii-h  the  lloors  of  \\w  an- 
I"''"""  ""'^  !'"-^l^'nor  cells,  and  then  uith  the  antero-po>terior  and 
lateral  clippers  cuts  away  as  much  of  thr  lloors  as  he  con^ider^  nece- 
^ary.     All  his  patients  treated  l.y  ,1,1^  nntlmd  were  relieved  an,i  ...me 


cured 


ill 


i   'I 


(  IIAPTKR  XXXI v. 


Sl'HKNOIl)  DISKASK. 


SiMi'i.i:  ciitiirrlial  di.-iiix'  dl'  I  lie  splionoid  sinuses  is  proiiahly,  like 
the  siiiiilar  disease  ol'  tlic  etiiuinicl  ci'lls,  of  frequent  occurrence.  Tiic 
syiiiploius,  however,  are  so  masked  hy  tlie  associated  diseases  of  the 
rhinal  i'ossa'  that  they  are  unol»sfrved,  and  tiie  course  and  recovery 
hccome  essentially  uiieveiitful.  Tlie  situation  of  th(;  sphenoid  sinus 
i<  seen  in  Fin.  5. 

Su])puration  of  (lie  sphenoid  sinus,  on  the  other  hand,  althoujrh 
still  very  ohscurc,  is  a  much  more  scrinus  afVeetion,  and  may  lead  to 
dangerous  results.  The  symptoms,  unfortunately,  are  not  by  any 
means  distinctive,  and  it  is  dilVicult  to  diagnose  it  with  any  degree 
of  certainty  from  the  ethmoid  disease.  The  etiological  and  patho- 
logical conditions  are  nnich  the  same;  and  the  deep-seated  pain  of 
the  j)ost-cthmoid  cells  is  dilTicult  to  distinguish  from  the  deep-soated 
jiain  of  the  sphenoid.  'I'lie  discharge,  similar  to  that  from  tlie  other 
accessory  cavities,  flows  more  naturally  down  the  post-pliarynx,  though 
a  certain  amount  linds  it  way  over  the  turbinated  bodies.  The  eye 
symptoms  are  also  similar,  inasmuch  as  a  larger  ])lane  of  the  sphenoid 
enters  into  the  formation  of  the  orbital  cavity  than  can  be  said  of 
the  etiimoid,  although  bulging  of  tht;  eyeball  is  usually  an  absent 
(juantily. 

In  some  cases  after  shrinkage  by  cocaine  the  jirobe  can  be  passed 
gently  upward  and  backward  over  the  lower  part  of  the  middle  tur- 
binated, between  it  and  the  septum  into  the  s[)lienoid  sinus,  and. 
after  drying  tlie  passage,  a  small  pledget  of  cotton  ])assed  in  on  a 
holder  would  indicate  whether  pus  was  in  the  sinus  or  not. 

J'latean  reports,  in  the  Joiirndl  of  fjariinfiolofiii,  etc.,  for  IS!)"). 
having  treated  2(i  cases  of  empyema  of  the  sphenoid.  Only  once  ha<l 
he  seen  it  in  connection  with  oza-na;  ])oly]»i  were  rarely  present,  ex- 
cept in  cases  in  which  the  ethmoid  and  s|)henoid  disease  were  asso- 
ciated with  each  other,  'i'he  most  comnuui  conijdication  fouiul  in 
this  large  r.uniber  wa<  with  disease  of  the  ethmoid  cells.  Tn  many 
cases  the  etiology  was  d(Uilitfiil.  but  in  other  eases  it  foUoweil  as  a 
secpiel  of  exantheniatons  disea.ses.  In  treatment  he  found  that  per- 
foration into  the  sinus,  with  subse(|uenl  cleansing  and  free  discharge, 
was  necessary,  llolbrook  Ciirti'^^  has  devised  an  instrument  for 
(1S(») 


I 


bl'IIKNOili    I)ISI:ASI:.       IltONT.VI,    diskask. 


isi 


iiTi<j;ating  the  siiuis  after  trephining,  tlie  ])atient  being  able  tti  intro- 
<iiice  the  tube  of  tlie  irrigator  into  the  sinus  withnut  dilliculty. 
Ilajek'e  liook  is  said  to  l)e  tlie  best  instrument  lov  curetting  the; 
eavity. 

IJosenburg  luis  lurnishcd  some  iu'eresting  facts  al)()Ul  lliis  nl}- 
scure  disease  wliich  are  worthy  of  mention,  lie  says  tliat  tiie  age 
of  jtatients  vary  fi'iun  ]1»  to  :>.">  yi'arr:.  and  th:.t  ii  never  arises  as  the 
residt  of  syj)liilis  or  serofida.  The  distance  from  the  spina  nasalis 
anterior  to  tlie  anterior  wall  of  the  sphenoid  sinus  i<  from  (>  to  7..' 
centimetres,  averaging  ('>.S  centimetres;  and  to  the  posterior  wall  nf 
the  same  from  7  to  10  ccntimi'tres,  averaging  8.5.  The  amniinl  of 
space  in  the  twc  nasal  fuss;e  varies  so  mucli  in  certain  cases  that  the 
twisted  se])tum  will  allow  a  probe  lo  be  passed  through  the  one  nasal 
fossa  into  the  siiiu-  on  the  opposite  side.  He  deseriix'S  the  sidijeetive 
symptoms  to  be:  burning  in  the  iu)se;  pain  at  the  root  of  the  nose, 
over  the  eye,  and  in  the  tcm]ioral  region;  shooling  pains  in  the  head, 
and  a  feeling  of  stulViness.  In  one  of  his  cases,  attendci  by  severe 
pain  in  the  head,  no  pus  could  be  seen,  but,  after  the  re  uoval  of  the 
hypertrophied  middle  turbinated,  ])us  ilowed  down  from  the  sinus 
and  the  pain  immediately  disajipeared. 

In  dealing  witli  (his  subject,  in  a  recent  able  article,  .Myles  says: 
''The  sphenoid  cells  are  not  so  dilficult  to  open  as  some  are  inclined 
to  think,  in  cases  where  the  septa  are  moderately  straight  and  where 
the  jiosterior  end  of  the  middle  turbinated  bone  has  been  removed, 
the  oozing  pus  can  be  easily  delected  at  the  point  of  the  natural  open- 
ing, high  up  ami  near  the  septum.  The  probe  will  often  enter  after 
caieful  use;  a  small,  sharp,  linn  curette  passed  in  and  Ihen  pulled 
outward  will  often  tear  away  the  sidt's  of  the  ojiening  sulliciently  for 
good  drainage.  T  ilo  not  consider  it  safe  to  curette  the  upper  and 
external  walls  of  these  sinuses.  Cart'fid  scraping  of  the  anterior  wall 
ami  the  floor  often  produces  decidedly  beneficial  results." 

I'ifON  r  AI.-SlMS    DlSKASK. 

Disease  of  Hie  reiiuiiiiiug  aci'cssory  cavity,  the  fi(Uita!  sinus,  is  a 
very  wide  subject,  and  an  exceedingly  important  nn(>.  It  falls  natu- 
rally, however,  under  the  domain  of  the  oculist,  ami  hence  is  usually 
treated  by  him.  'i'his  vohune  is  a  treatise  upon  the  nose  and  throat 
(Uily,  and,  conseipiently,  can  leave  fronlal-sinu-;  disease,  without  ju'cju- 
dice,  within  (he  limits  of  its  own  ))roper  sphere  (Fig.  2). 


'   -l  H 


f 


! 


!i 


m 


ll 


If. 


£ 


SECTION  II. 


Diseases  of  th(>  Pharynx. 


li 


if 

■fa 


"1^    . 


m 


n 


.1 


\ 

i        1 ' 

(  llAiTKU  XXXV. 


ANATOMY  OK  TlIK   IMIAKW-X. 

Till;  jiliiiryiix  is  a  iiiusrulo-iiH'iiiliiiiiiPU.s  .-;k-,  lying  'irlwci'ii  tlu' 
hack  of  the  noso  ami  tlic  (I'sopliagus.  Thr  base  is  iipwaid  Ix'iuMlli  I  he 
base  i)i  the  skuU,  and  llie  apex  downward  trniiiiiatiiig  in  the  (I'soph- 
agus,  and  on  a  li'vcl  with  tlic  crii'oid  carlihigv'  and  lilth  ciTviial 
vertehra.  It  is  .-iliiatcd  hchind  the  no-c,  nioulh,  anti  hiryiix.  In 
length  il  is  Ix'twi.en  tm  and  eleven  i-eiii  iimtres.  and  it  is  limader 
laterally  than  iielore  haikwanl.  lis  greatest  hicadlh  is  midway  lie- 
tween  tlie  jialate'  and  the  (e.-(i|)hagus,  and  its  nai'r()we.-l  at  the  lesipph- 
ageal  termination  (I'igs.  TO  and  71). 

The  houndaries  oi'  the  ]>haryn\  are,  as  I'dol'.  the  liasilar  pr(pee>s  of 
the  oeeiitil.d  lioiie;  and,  as  lloor,  the  entrance  to  the  (esophagus,  the 
right  and  left  sinn.-  pyrifoiinis,  and  the  aryteimid  cartilages  and  I'om- 
inissnre  of  the  larynx,  rn-teiiorly  it  is  separated  from  the  iipjier 
four  cervical  vertebra'  in  the  lentre  and  the  reeti  capitis  antici  ami 
Iniigi  cdlli  inuscdes  at  the  sides  by  loose  areolar  tissue.  The  promi- 
nence of  the  arch  id'  t1ie  alias  may  oi'leii  be  recognized  near  the  upper 
cMreinity  of  this  .--uil'aiH'.  Tiic  iiiiterior  hiuindaiy  i-;  f(Uincd  by  toe 
posterior  nares.  Mjiarated  by  the  \(inier.  the  internal  pterygoid  plates, 
the  soft  ]ialatc,  the  t(Uigue  when  the  mouth  is  closed,  the  hyoid  bone, 
iind  the  epiglottis.  Mach  lateral  wall  is  marked  at  its  uppiT  eml  by 
the  pharyngeal  (U-ilice  cd'  the  l'".u?taehian  tube  ami  the  I'os.-a  of  K'om'U- 
uiiiller.  ami  is  connected  with  the  >lyloid  processes  and  Ihi'ir  muscles. 
This  wall  is  also  in  I'ontact  with  the  common  and  internal  carotid 
arteries  and  internal  jugular  veins  and  with  the  eightli.  ninth,  ami 
symjiathetie  nerves. 

There  are  seven  openings  into  tlu'  pharynx:  the  two  piistcrior 
nares,  the  two  iMistaeliian  tubes,  the  UKUitli,  the  larynx,  and  the 
(esophagus.  As  described  in  dealing  with  the  tuiM'.  the  |io>terior 
nares  are  the  oval  openings  which  enter  the  |iharyux  on  the  anterior 
wall  almost  on  a  level  with  the  vault.  The  two  j-liistachian  tubes 
opi'U  one  on  each  side  of  the  pharynx,  almost  directly  behind  the  in- 
ferior meatus.  The  miuiili.-  (d'  these  lubes  are  ovoid,  or  funnel- 
sliai)ed;  Ifoosa  describes  them  as  ■"trumpet-shaped  orifices,  nine  milli- 
metres high  and  five  millimetres  broad."'     The  opening  of  the  tul)e 

(185) 


I'll 


•I  :■•! 


il  If 


T 

r 

1  '';■ 

■ 
1 

1 
i 

! 
1 

! 

1 

! 

18(5 


DISKASKS    UK    niK    I'HAHYN.X. 


is  ]i,'irlly  .-iirioiiiuk'd  by  a  cartiliiginous  ring,  which  in  iiior^t  jjromiiu'nt 
jiostorinrly  iind  ahovo,  lifrhtcr  in  front,  and  aliscnt  lioncath.  liohind 
the  I'liistaehian  orifice,  and  hclwcfn  it  and  the  posterior  wall  of  the 
pharynx  its  an  eimiixati'd  (h'prcssion:  the  I'ossa  of  Hosenniiiller.  While 
at  rest  the  Kustaohian  orifice  in  closed;   hnt  in  the  various  motions  of 


H' 


Nasopharynx.  < 


Oro-pliarynx.  ^ 


Laryiif^o-iihaiynx. 


rif^.  70.-  Si'ctioiuil  \  i«'w  of  tlie  pliurynx.  1.  Left  Eustachian  tube. 
2,  I.oft  fossa  of  Kosonniiillrr.  3,  Palate  and  uvula.  4,  Tongue.  5,  Left 
tonsil.  6,  0,  Upper  and  lower  houndary  of  larynx  (epiglottis  and  cricoid 
rartiliige).  7,  Cavity  of  narcs.  8,  Cavity  of  mouth.  (After  Lennox 
Browne.) 


>»i: 


the  fauces  it  is  frequently  opened  hy  the  contraction  of  the  tensor- 
palati  muscles. 

Directly  l)e]iind  and  below  the  posterior  narcs  lies  the  superior 
surface  of  tlie  soft  palate,  with  the  uvula  in  its  centre.  Below  that  the 
mouth,  then  the  l)ase  of  the  tongue,  epiglottis,  and  larynx.  The 
oesophageal  opening  is  the  apex  of  the  pharyngeal  cavity. 


il:K 


IP 


r- 


l'"ii.'.  71.  l-'ni/t'ii  ~i'(linii.  Siiic  \ic\\  nt'  ii"-i'.  |iliaiyii\.  iiinl  hirviix  of 
iliild.  iijicd  :>  \ciir-.  I.  I'mdv  (il  •i|p|iciinicl.  1.  I'll  liiiKiid  cells  :itid  -ii]>i'ricii- 
llK'iltUs.  :!.  Middli'  llii  liiiiiilcd  l"iiic.  4.  Midillf  iiiralii-.  .">.  Iiifciior  liir 
liiiiat('<l  liniit'.  11.  XCstilndc  uf  llic  nose.  7.  Sii|n'ii(ir  iiiiixillaiy  liniic.  s. 
Soft  palatf.  !•.  TciiiiiiK'.  Id.  Na-i()|iliar.\  ii\.  II.  I'!|ii,i;lnt(  is.  |-J.  |,aryn\. 
I  l''r(iiii    I'liiiirusc"-.   .\iia1iiiiii(al    Miisiimi.    I'liix  crsilv   <it   'riirniitd.  i 


I 


: 


ANAIOMV    UK    Tin:    I'll  \ltVN\. 


isn 


'I'lit'  |ili;irviix  is  fuiiipnM'd  ui  tlirci'  ((iiil*:  ii  iiiiunii.-  ciiat,  a  Uliruu.s 
cnjit.  iiiul  a  niiiscuhir  layor  hi'iu'iitli.  'I'lu'  iiiiisciilar  cnat  {•()iisi.>ts  of 
the  .-uinridr,  iiiiildlc.  and  iiifcridi-  coii.-t riilnr.-;  tin-  Icvaturcs  palati, 
mid  the  ti'iisorcs  palati.  to^itlur  uiili  the  >t_\  lt>-pliai_viii:<'i  and  |ialato- 
jilianiiLTfi  ami  |ialat<>-^i()>..i  iniisclfs,  a  I'ldlcr  acciniiit  nl'  uliidi  wdl 
1)0  I'uiiiid  in  the  standard  wniks  dii  atiatnniy  (Ki;,'.  t'-i). 

Tlic  (ilinuis  coat  is  sitiiatol  lictwci'ii  tin'  iiiiisciilar  and  iniicnn-; 
layers;   and  is  termed  tlie  |iliaryn;:i'al  a|iiineiir(isis.     It  i»  thick  ai)ove. 


'* 


('(•l)lialo- 
or  Naso    |iliiiryn\.    ' 


Ilyo-  (ir 
(Mil    jiliaryiiN.   < 


F.iiryti>,'o- 
|iliiiiyii\.    ' 


]"ip.  7'2.  7  ho  niusclcs  of  ttip  soft  juilato  and  pliaryiix:  tlie  pliarynx 
laid  open  frotn  t)rJiind  (niodilitd  from  (Jiay).  1,  1,  Lcvutorcs  pahiti,  the 
loft  lioitifj  out  short  noar  to  its  oriijiii.  2,  12,  Toiisoros  palati,  tho  loft  siiow  - 
inj;  its  rofloctocl  tondon  and  relation  to  tho  hainular  process  {a).  ,3,  .'t. 
I'alato  plossi  (.antorior  pillars  of  tho  fanoos).  4,  4,  Palato-pharynfjoi  (pos- 
terior pillars  of  the  faiicos).  5,  5,  Tonsils.  0,  A/y};ns  tivnltv.  7,  Uvula. 
S,  8,  Eustaohian  tubes.  9,  0,  Inferior  constrietors  (larynfjo-pharynfjoi). 
10,  10,  ^liddle  eonstrietors  (hyo-  or  oro-  pharyn<;ei).  11,  11,  Superior 
oonstrietors  (ccphalo-  or  naso-  |)harj'nfTei).  12,  12,  Epiglottis  and  laryn.x 
not  laid  open.      f.Vftor  Lennox  Browne). 


I  i 


I  I 


IDII 


DISKASMS   OK   TIIK    I'HAUYNX. 


Ilcn-  tlic  niu>('iilar  lilms  arc  iiiisciii  ami  llic  lilinni.'*  cual  i>  altadicd 
lirnily  tn  llir  li.i>ilar  pi'iH'cSii;  of  llu-  iM'ri|iiial  ami  ilic  |i*'irniis  |)nrtiiiii 
of  I  lie  tcm|ii'i-,i!  liiiiH'.  As  ii  (IcMcml.-,  it  licinMics  ^rradiially  li»t  in 
llic   Hue  iiiiL-ciiLii'  cital    lii'iiciitli   it. 

Till'  iiiiicdii-  liiviT  is  iiiiitimiiiii.«  with  that  ul'  ihr  iiair-.,  Mii- 
slachian  tiilirs,  iin<iilh.  iiiid  lai'Viix.  'I'Ih'  ii|i|m'|'  .^iirlaii'  i>|'  thf  Mij't 
palati',  with  (he  \aiill  ul'  the  |>liai'vii\  dnw  n  as  lnu  as  llir  llo  ir  of  llir 
iiai'i's,  is  I'oNi'i'id  uitii  (iijiiiiiiiai'  cdiatcil  I'lnthciiiiiiu  while  in  thr  oral 
part  of  till'  pliar\>i\.  IhIow  ihc  palalf.  ihi'  cpiiiii  liiim  is  of  the 
siinaiiioiis  variciv , 

'I'lic  iiioxciiicMl-  of  ihr  soft  palaii'  aic  lonliojlcd  liv  ihr  Icvator- 
palati.    palato-|»hai\vii.L;ti.    ami    a/\\i;o«-ii\  ida'    iiiii-clcs.    of    which    this 

llr\ili|c    piece    of    me(haili»lll     i-    (•o||ipo>ed.       Se\e|al    of    ihe-e    !llll>il('» 

have  al.-o  a  direct  relation  to  the  I'.ii-lai  liiaii  tnhe>  hy  opciiiiiLr  theiii 
wlieti  Tieces>ary  to  admit  the  i  iitraiice  of  air. 

'I  he  pharvii'jial  i:laiiil>  are  of  two  kiml.«:  lln  follicular,  -iiiiple 
and  compniind. -caller(  d  t  hi'oiiiiliniii  the  pliar_\n\  lieiiealh  llie  iiincoii- 
iiicnihrane;  and  llie  racciii<i-e.  in  the  upper  |iliar_vn\  helwccii  ihe 
I'liislachiaii    |iilie~. 

'i'lic  arterie-  are  >iippli(d  frmn  the  a-cendiiiLr  pharyii.LTeal.  the 
jialatal  hraneh  of  the  facial.  toL'cthcr  with  hraiicho.s  of  the  internal 
maxillary. 

The   \cins  Ciller   inlo   the   inlcrnal  jnL.Milar. 

'i'he  iier\cs  are  derived  from  the  second  and  lliinl  divi-ion-  of 
the  tiflh,  to^-cihcr  with   hram-hes  from  the  e|i)>.;,i-|i|iiii  viiLTcal  and   llie 


vaiTiis. 


ic  pharynv.  owinu'  to  its  rclalinn  In  the  nose  at  the  oiu'  end, 
and  the  lar\n\  and  (e,-npliai:iis  at  (he  other,  (oi:ether  wilh  the  fact 
that  its  posti'rioi'  wall  i.-  an  nninterrupled  siiid'ace.  may  he  considered 
as  a  single  division  (d'  the  respiratory  tiact.  For  physioloudcal  as 
Mcll  as  palh(dou;ieal  rcaMiiis,  however,  it  is  u>ually  considered  to  \)v 
divided  into  two  sections  hy  ihe  soft  Malato,  known  a^  the  nasn- 
pharynx  ami  the  oro-pharynx. 

in  the  nasii-pliarynx,  the  tissue  or  plu.i'yiiLreal  tonsil  >ituatcd  on 
the  hack  wail  and  upon  the  hase  (d'  the  occipital  hone,  and  known 
by  the  older  anatomists  as  tlu'  racemose  irlaiids,  frcipicntly  nnderjrocs 
oiiorinoiis  development  (Fij:s.  T;>  am'  Tl).  In  its  natural  state  it  pre- 
Fcnts  a  .«oft,  cnsliion-like  surface.  It  is  sometimes  covered  with 
rounded  elevations.  At  otliers  divided  hy  deeji  fissures,  runninij;  chiefly 
in  a  per])endicnlar  or  lonuitudinal  direction.     This  mass  of  ijlamls  is 


!    I 


;l(  t 


on 

All 

rt'- 

th 

"lly 

is 


ANATOMY    <»K   Till:    I'llAHYNX. 


191 


cnllcil  tln'  |ili!ir\  ii^riil  tiin:'il,  (T  I-ii-clika's  tnnsil.  in  liMimr  ul  tlif  iniiii 
uIki  liist  l:ii\''  ii  lull  imntiiiuiciil  <l('Sfripti<iti  of  it.  In  llir  jnut  r  |i;iri  n|" 
til*'  tiiii..il  III  ill*'  iiii'ijiiil  line  is  smiirtiiiu's  loiind  a  siiuill  uiicniiii:  li'iiiliii.i; 
into  tlic  >i\f.  ciillfd  till'  Itiirsa  itliarvii^rca.     'I'liis  sac  iiiav  lif  I'nun  niu* 

III   Iwn    tflllilllrtrrs    liillL.'   ilinl    Irolll    tlllCc    In   si\    III  ill  llllcl  fi-    \U(I».       Ill 

till'  iiaiiiiiil  -lalc  till-  |iliaiviiui  al  cii-liiun  ^Imiilil  iirMi'  in  aiiv  pail 
nt'  it  lie  iiiMji'  than  I'nur  t<i  .-iv  iniHlnirtrt'.-.  in  lliickiu',--.  ^'railiially 
lliiniiiiiL'  away  Inuaiil  il-  miti  i'  inaiLini-. 

'I'll  r    I'  \i  I  I  \  I    'ruNsii.s. 

'I'llf^f    \\\<t    lOlind    nV    alll|n|l(|-.-|iapl(|     linilir«    (1(1    IKit     llcldllL'    I"    IlK' 

|i!iai\n\  |irii|i('r.  Inn  arc  -cparalcd  iidiii  il  (Hi  cadi  -idc  \>\  (iic  palalo- 
pliai\  iit:cii«  iiiii-(  Ic.  Till  y  lie  liciwccn  ihc  antciidr  ami  pd-tcrjor  pil- 
lai>  (if  the  I'aiicc*.  and  diii(tl\  ain'Vc  the  Ka-c  nf  the  Idicjuc.  'I'licir 
direct  anat'iinical  rclalidii.-  arc  ihn-  (lc-cril(((|  hy  l>clavan:  "The  rc- 
latinii>  d!"  Ihc  Idii-ij  'ii  the  inleiiial  carnlid  artciv  arc  iidt  so  intiinatc 
as  cdiiiiiidnly  -nppdscd,  I'dr  hel\\(cii  the  laleial  uall  dl  the  pharynx, 
the  inlcnial  plci'vuniii.  and  ihc  upper  cervical  vcrlchia'  there  is  a 
s|»aee  (illcd  with  cdliihir  ti.-siic.  the  pliaryiiird-maxillaiy  inlerspace. 
ill  the  pd-li  iidr  pari  i>(  uhii  h  arc  locfited  the  lar^c  vc>scN  and  nerves, 
and  which  lies  alnid^t  dircdly  hackuard  I'rdiii  ihc  pharynnd-palatine 
arch,  'i'lie  tdii>i|  Cdric-pdiid-  to  llic  aiilciidr  pari  dl'  lhi»  interspace. 
.-(>  that  lidtli  eai'dlids  arc  hchiiid  it.  -the  iiiicrnal  cardlid  dUc  and 
live-tciiths  ceiiliinct  res.  the  cMeriial  cardlid  lud  cent  iiiicl  res.  distant 
Troiii  its  lateral  peri|ihery." 

The  t'Uisil  may  iie  dcserilied  as  cdinpd-cd  (d'  lyniphnid  li>>uc.  It 
presents  nii  its  (inter  -iirl'aee  a  nuiiilier  id'  orifices  varyiiiLi'  I'min  five 
or  six  to  a  dozen  in  niimhcr.  leading;'  ddun  td  the  deep  crvpt-  of  ilic 
tonsil,  licsides  tlii>e.  fidiii  tlic  rc>earclic«  id'  His.  and  iliiriii;^'  the  past 
year  of  1>.  X.  I'atcrsnn.  \\e  have  had  diauii  to  mir  notice  the  evistciieo 
ill  tlio  upper  part  of  the  inn-il  id'  an  anatoiiiical  space  called  the 
-npratonsillar  fo>sa.  In  the  majdriiy  nf  instances  careful  examina- 
lioit  will  reveal  a  >mall  recess  in  this  sitnatidii,  clusc  In  the  anterior 
palatal  arch,  liavini:  a  diU'ereiit  fdldiii'i  and  hein,::'  mucli  lai'L'er  in 
every  way  than  an  ordinary  crypt. 

In  youiii;'  sidijects.  particularly,  a  wch  nf  ineiiilnane  is  frciiiicntly 
attached  to  the  hdi'dcr  of  the  anterior  pillar,  cxfeiidinu'  downward 
and  hack  ward  over  ihc  toii-il.  It  is  called  I  he  plica  trianirularis:  and 
it  is  hetweon  this  ]dica  and  the  ii]iper  portion  of  the  tmisil  that  tlio 
snpratonsillar  fossa  is  foniid. 


III 


in; 


DISEASES    or    THE    PHARYNX. 


Tho  lyni])lioid  tissue  consists  of  two  kinds:  lympli-piilp  and 
lyinpli-nodules.  Tlio  pulp  constitutes  tliu  greater  part  of  the  tonsil. 
The  nodules  form  ten  or  twelve  oval  or  round  masses,  immediately 
below  the  walls  of  the  erypts,  and  situated  within  the  lymph-pulp. 
They  dilfer  from,  while  in  some  respects  they  rcsciid)lc,  tlie  Mal- 
pi;fhiaii  hudit's  nf  ihe  spleen.  Tliey  are  surrounded  hy  a  dark  zone  of 
reticular  tissue. 

The  lyini)li-pul|)  consists  (>f  lymphocytes  inclosed  in  a  delicate 
reticulum.  The  cells  are  lar;:t'r  and  the  reticulum  coarser  than  in 
tho  nodules.  The  reticulum  is  fornu'd  of  elonpded  cells  inclosinL:j 
lymiih-spaees  through  wlmse  walls  lymph  and  migratory  corpu.^les 
readily  pass  from  the  capillaries.     (Lennn.v  IJi'owne.) 

Thi;  LiNciAi.  Tonsils. 

At  the  hase  df  the  tonuue  on  either  side  of  the  ,<:losso-epiji;lotlic 
lold  are  situated  two  irrcizular  nodular  masses,  varyin^tx  widely  in 
degree  of  developnu'iit  and  of  form.  These  are  known  as  (he  lingual 
tonsils,  llisfdiiigieally  they  ai'e  identical  with  the  i'aucial  tonsils. 
The  crypts  are  sometimes,  however,  lined  witli  ciliad'd  epilludium, 
and  the  cellular  tissue  is  mine  dense  than  in  (he  i'aucial  region. 
Another  important  point  in  regard  to  them:  they  freiinently  do  not 
commence  to  develop  until  adult  life, — the  ]ieriod  when  the  faucial 
tonsils  have  commenced  to  disappear. 


lii 


fiiAi''ii:u  xxxvi. 


PiiYSioi.ocv  OF  III!-;  i'iiAi;v\x. 


Till-;  ])hysiulnifical  fiiiictit)iis  of  the  iiaM)-|)liiirviii:\'al  iiml  (uo- 
l)liaryng(.'al  divi.^idiis  of  the  plinryiix  an.'  in  .-oiiio  rcspucls  very  <lis- 
tinet  from  each  other. 

The  foriiicr  ha-  hirgely  respiralni'v  fiiiictii)n.s  to  perforin,  and. 
like  tile  li;\ver  half  of  the  nasal  pa.ssages,  is  .-npplied  wiih  cohinuiar 
ciliated  epithelinni.  lo  aid  in  keejting  the  ])as.saue  free  from  any 
secretions  which  might  im])ede  normal  respiration.  The  naso-pharynx 
is  also  richly  endowed  with  the  glands  (d'  the  pliaryiigeal  tonsil,  whose 
s])eeial  function  api)ears  to  he  to  secrete  clear,  C(dorlcss  nuu^ns  for 
the  purpose  of  moistening  and  keeping  pliahle  the  surrounding  tis- 
sues and  to  help  to  lubricate  the  food  ere  it  leaves  the  ()ro-])harynx 
for  the  lower  alimentary  canal. 

The  sid't  palate,  or  velum  peiidnlnni  palati,  hanging  m  mid- 
position  in  the  ])harynx,  has  several  functional  duties  to  perform. 
Hy  ])ressing  tightly  the  ]io>t-phai'yngeal  wall  diiriii'i  the  act  of 
swallowing,  it  completely  divides  the  pharynx  into  two  jiarts,  and 
etfeclually  iircvents  food  whether  solid  or  lluid  from  entering  llu' 
naso-pharynx.  At  the  same  tinw.  hy  its  jiressure  u|iward  ami  back- 
\vard,  it  forces  down  into  the  oial  cavity  the  nnicons  secretion  already 
spoken  of.  ll  also  ])lays  a  very  important  pai't  in  the  fuiu-tion  of 
voiee-production,  which  will  he  spoken  of  mon'  fully  when  dt'aling 
with  the  larynx. 

The  tissues  of  the  oro-pharynx  are  of  harder  and  denser  texture 
Than  those  (d'  the  naso-pharynx.  Tiiis  enables  it  to  perform  the 
duties  of  deglutition  without  injury  to  its  llexible  surface.  It  has 
fewer  glands  than  the  naso-pharynx,  and  depends  largely  for  the 
moisture  and  lubi'ication  it  reipnres  upon  the  salivary  glands  and  the 
mucous  discharge  from  the  jiharyngeal  tonsil. 

Deglutition  is  a  complex  movement.  After  mastication  the  food 
is  forced  backward  by  the  t'muue  pressing  gradually  fr(uu  the  lip 
to  the  base  against  the  hard  ))alate.  As  it  reaches  the  pharynx,  the 
faucial  muscles  come  into  play,  forcing  it  still  farther  backward  and 
downward,  while  the  i)alato-i)haryngei  and  levator-palati  muscles  pre- 

(193) 


il« 


11  i 


394 


niSKASKS    OF    THK    IMIAUYNX. 


vent  its  pjissii^fc  into  tlic  ii|»|)ur  pharynx.  At  tlic  moment  tliat  tin* 
fancial  muscles  eoiilraet,  tlie  miHcles  of  the  liyoid  bone  draw  up  the 
larynx  Itehind  the  base  oJ'  tli<'  ton;.aie.  l>y  means  of  tliis  comph'X  move- 
ment tlie  epi^hittis  is  tilted  l)aek\\!ird,  and  the  whole  of  tlie  oro- 
pliarvnx  is  transformed  into  a  funnel,  down  which  the  food  is  forced 
hy  muscular  action  into  the  tcsophaj^us. 

'J'he  pliysioio^ical  fuiutions  (d'  the  tonsils  liav(^  h)njj;  l)een  an 
oljject  of  investi,iration.  Formerly  it  was  the  prevailing  impression 
that  they  were  secret iiiLi'  bodies,  the  object  (d'  the  secretion  hein^  to 
prepare  the  food  for  dcLilutition.  At  a  latter  (hiy  it  was  claimed  that, 
like  lymphatic  structures  generally,  iheir  nussion  was  the  production 
of  white  eor|)US(des  of  the  l)lood.  Jlingston  Fox  and  Seanes  Spicer 
lield  this  view,  while  the  former  gave  them  another  mission:  ihat 
of  reahsorption  of  the  salivary  secretions  after  defrlutition  had  been 
accomjilished.  Swain  suggests  that  tiieir  real  function  may  lie  ti> 
destroy  jiathogeuic  germs  entering  the  mouth  with  the  food;  thu.-. 
the  lymphatic  cells  or  leucocytes  of  tlu.'  tonsils  would  do  the  work  of 
scavengers  or  phagocytes.  J'osworth  believes  that,  whatever  tlu'ii' 
function,  they  are  really  absorbent  organs,  and  that  yet  the  crypts  and 
tubular  glands  of  the  tonsil  would  iTidicafe  a  secretory  power,  how- 
ever limited.  Bruschke  is  of  tlu;  opinion  thai  the  tonsil,  without 
being  ulcerated  or  inllanu'd,  may  be  the  |)oint  of  entrance  for  pyo- 
genic micro-organisms.  Semon  also  found  evidence  that  the  infect- 
ing micro-organisms  in  septic  inllammalion  of  the  pharynx  gain 
entrance  through  the  tonsillar  crypts:  and  Wagner,  of  San  Francisco. 
has  shown  that  rheumatism  may  be  due  to  migration  (d'  germs  from 
the  tonsillar  tissiu'.  lie  has  fouiul  the  same  micro-organisms  in  the 
synovial  fluid  of  the  knee-joint  in  two  instances,  and  in  the  urine  of 
nearly  all  his  eases,  as  existed  in  their  diseased  tonsils,  of  which  the 
clinical  history  proved  they  were  (piite  free,  [irior  to  the  attack  of 
tonsillar  disease. 

These  opinions  would  seem  to  be  ai  variance  with  the  somewhat 
prevalent  one,  of  ili(>  existence  of  ])hysiological.  tonsillar  pliagocytosis. 


DISKASKS  OK  'I'll  I".   XASO-I'HAK  VN  X. 


ClIArTKH  XXX VII. 
N'Aso  i'iiai;v\(;i:ai.  cataimiii. 

'rjii>  disease  niiiy  iipiHiir  in  an  aciHi'  or  c-hronic  I'lU'iii.  Ii  is 
sdiiicwiiat  rare.  liowi'Ver.  I'm'  it  to  fall  intn  tln'  liamls  nf  the  iihysician 
ill  I  he  acute  slajre.  When  it  (1(H's,  it  is  usually  an  (•\ti'n>ion  of  or 
accniiipaiiiiiiciif  to  acute  rliiiiiti-.  as  the  ili.-ca-i'  i-  iiKirc  likely  to  cx- 
tfiid  from  liefni'c  backward  than  fri)tn  the  lower  pharynx  to  the 
vault  above.  When  ft)rtunately  treated  as  an  acute  disease,  it  is  at- 
ten<led  by  similar  sym[)toms  to  those  of  acute  rhiniti-,  and,  lieini;' 
associated  with  it,  is  amenable  to  similar  treatment. 

Tlu'  subacute,  or  chronic,  bu'in.  however.  re([ui!'e>  distinct  con- 
sideration. 

Pathology. — In  this  disease  thei'e  is  thickeneil  na.-o-pharynucal 
mucosa  alTeetini:  particularly  the  muciparous  Lrlands  of  the  pharyn- 
geal tonsil.  Wiiercver  these  irlamls  are  clustered  to.trethei'  in  large 
uumbcrs,  there  is  a  preclisposition  to  chronic  inllammatory  disease 
and  cell-des(|uamation.  This  is  particularly  so  in  ihe  |iharynfreal 
vault;  and,  whenever  a  proximate  cause  exists,  a  muco-iiurulent  dis- 
charge from  the  evenly-distributed  mass  of  glandular  structures  may 
be  tlic  result.  This  chronic  inllammatory  action  is  usually  attendeil 
liy  more  or  less  hyperplasia.  liosworth  believes  that  the  sac  or  cavity 
called  Luschka's  or  Tcu'nwaldt's  bursa  is  not  a  natural  condition,  but 
the  result  of  inllammatory  action.  I'y  it.  the  iwn  lateral  lobe-,  into 
which  the  pharyngeal  tcmsil  is  sometimes  divided,  ai'c  swollen  ami 
crowded  together,  and  the  superficial  layer  (d"  epithelium  on  the  (uie 
side  unites  with  the  epithtdial  layer  on  the  other,  the  intei'ior  being 
left  open,  thus  forming  the  so-called  luirsa. 

in  th(>se  cases,  as  well  as  those  in  which  the  hyperplasia  is  more 
uniform  ami  unattended  l)y  bursal  dovelopnu'nt,  the  surface  nuiy 
assume  a  mamnullated  or  raspberry-like  contour.     This  lymph-tissuo 

(IDa) 


111 


W 

m 


d( 


iii 


;  I-     I 


i'JO 


DISKASKS    Ol'    JlIi;    I'llAUYNX. 


I 


is  well  supplied  with  blood-vessels,  but  with  few  acinous  glands,  and 
hence  is  dilVerently  formed  than  ordiiuiry  gland-tissue.  It  is  supposed 
that  tiie  increased  secreli(jii,  not  liaving  an  aciiu)us  origin,  must  be 
formed  in  the  sulci  or  fissures  which  separate  the  hypertrophied  lobules 
from  each  other.  When  Tdi'uwaldt's  bursa  exists,  its  lining  mem- 
brane may  also  proihu'e  much  of  the  discharge  which  occurs  in  this 
disease. 

Etiology. — Meteorological  changes  in  atmospheric  conditions  are 
fre(juenfly  the  exciting  cause  of  this  disease,  particularly  on  the  lower 
levels  and  along  the  uatei'-ways.  Throughout  the  extensive  lake- 
region  of  North  America  this  disease  is  very  common.  The  cold,  damp 
winds  that  prevail  so  extensively  along  the  laki's  iluring  the  change- 
able seasojis  of  fall  and  spring,  cliilling  the  cutaneous  surfaces,  pro- 
duce congestion  of  the  naso-pharyiigeal  mucosa  and  lead  to  the  chronic 
inflammation  which  exists  so  widely  during  these  seasons  of  the  year. 
Iidialed  dust  may  also  be  a  factor  in  some  cases.  l)ut  can  only  lie  of 
moment  wlicii  tlic  situation  is  di'v  and  elevated  and  away  from  the 
hike-region. 

In  mountainous  districts.  Imwcvcr,  and  on  the  extensive  iidand 
prairies  there  may  mii  be  sullicicut  natural  cxosmnsis  from  the  tur- 
biiialt'ds  to  saturate  the  air  as  it  is  ins[)ir(Ml.  In  ihese  cases  dry,  dusty 
air  may  pass  through  the  nares  aiul  strike  against  the  post-iihniynu-eal 
wall,  inducing  chronic  iiiliammation  and  catarrh. 

The  conse(iuence  is  that  these  two  causes  alone,  from  theii-  varied 
features  of  humidity  and  altitude,  may  produce  two  entirely  dilVen'ut 
varieties  of  post-nasal  catai'rh:  the  luie  hypertrophic,  the  other  atro- 
jjhic.  Or,  in  other  words,  the  "moist"  catarrh  prevails  with  the  lake- 
<lwellers,  while  the  "dry"  catarrl   holds  sway  upon  the  elevated  plains. 

The  tendency  among  chih.ren  to  disease  of  lym])hatic  tissues 
would  lead  us  to  look  for  nar.)-])haryngi'al  catarrh  most  freipu'iilly  in 
early  life;  ^louri  .says  tliat  it  is  even  common  among  infants. 

We  ai'c  not  sufhciently  cognizant  of  the  fact  that  une([ual  nasal 
hreathing  beai's,  in  many  instances,  a  direct  relation  to  it  also.  In  a 
large  munber  of  instances  the  eomjiarative  respiratory  freedom  of  the 
two  nostrils  bears  the  relation  of  one  to  two  or  one  to  three.  What- 
ever produces  freedom  of  res])iration  In  one  nostril  at  the  expense  of 
the  other  tends  to  accumulation  of  secretion  behind  tlu'  stenosed  re- 
gion, and  that  accumulation  results  in  disorganization  of  tissue  and 
catarrhal  disi'ase. 

Charles  Knight  has  shown  conclusively  that  exostosis  of  the  sep- 


N'ASO-l'HARYNGEAL   CATAUIUI. 


1!»1 


luiii  is  a  fi'LHjiiL'iu  causo  of  chroiiio  iiaso-plianni^tal  dirioaso.  Tlu' 
l/oiiy  projt'otioii  is  usually  in  the  i'unu  of  a  souunvliat  irrogular  ridm' 
niniiin<,^  froui  before  backward  alonj,'  the  osseous  sepluin.  parallel  with 
the  lluor  of  the  iio.-r.  Soinetiiues  it  is  even  adherent  to  the  infeiiof 
(iiriiiiiated.  l)i>ehar;:('s  are  retained  liehind  the  obstruetiou,  oti'a- 
sioiiiuLT  ]iutrefaetioii  ami  conseipieiit  iuereased  irritation.  Wliile  eon- 
(k'luiiinii'  nllicious  operative^  treatment  in  all  cases,  the  indieations  are 
elear  to  remove  the  ohstrnetive  lesion  and  hv  this  means  to  produce 
etlicient  diainaLic. 

]n  atr()|)liie  rhinitis  naso-pharyn^n'al  catarrh  is  always  tlie  result, 
'i'he  vault  of  the  pharynx  is  in  no  way  supplied  with  the  ven'ous  sinuses 
of  the  turhinateds;  so  when  the  air,  nn  account  of  turhiual  atrophy, 
fails  to  reach  the  ])oint  of  saluiation  in  passiiiL:'  thr<iunh  the  nasal 
])a>>ai;es.  it  (piiekly  dries  u])  the  seaidy  secretion  of  the  phai'yn-''eal 
vault,  Icavinii-  hei'e  the  inspissated  mucus,  which  it  is  so  often  dillicull 
to  remo\c. 

This  disease  is  said  to  he  more  prevalent  in  America  than  in  Ku- 
ropc. 

Another  cause,  parliculai'iy  in  oui'  iai'^e  cities,  owes  its  orijiin  to 
our  suj)posed  advaiucd  civilizalion.  Naso-pharyn.ii'eal  catarih  anion,:^' 
the  ahoriyiiU'S  of  the  various  continents  is  almost  an  unknown  ([uaii- 
tity;  hut  in  our  fnrnacedu'ated  homes,  with  tlic  intciisi;  dryne^s  of 
the  air,  it  is  anioULT  the  commoiu'st  of  catarrhal  atl'eclioi'.s. 

Let  a  man  wearing;'  speciades  enter  a  house  in  tlie  wiider-lime 
comfcu'tahly  heated  by  >toves  oi'  lire-])laces,  and  immediately  ilie  nioi.-t- 
ure  of  the  atmo.-phere  will  condense  upon  the  j,dasses,  and  make  vision 
throu.trh  them  impossible;  and  without  he  dries  them,  it  will  take  sev- 
eral miindes  helore  the  ^la.->  will  acijuire  the  teiuju'ratiin  of  the  room, 
and  pernut  of  dryiui;-  by  evap(ualion.  l>ct  the  same  man,  on  the  othei' 
hand,  enter  a  house  heated  by  a  hot-air  furnace,  and  the  ylass  will  re- 
main iterfectly  dry,  inasnnich  as  the  air  contains  too  little  moisture  to 
))ei'mit  of  condensation. 

The  rcas(ui  of  this  is  that  furmic(!  manul'actui'eis  hav(.'  too  little 
knowledge  of  pneumatics  and  hydrostatics  to  build  furnaces  correctly. 
A  water-])an  for  evaporation  i>  supplied  with  each  liirnace;  but  il  is 
usually  altogether  too  small  ami  too  remote  from  the  lire  to  he  of 
material  l)ene(lt.  My  own  furnace  is  a  case  in  poiid.  It  was  consti- 
tided  on  tlu;  regular  ortluxhtx  ]ilan  ami  the  water-pan  evaporated  a 
pailful  of  water  per  day.  Ihit  the  air  was  so  dry  as  to  he  distressing 
to  the  nuicous  mendu'anes.    Thi-  hnted  oiu'  winter.    The  second  season 


M 


iliill 


!■    i 


nil 


iil 


11»8 


Dlt^KASKS    Ol'"    Tin;    I'llAUV.NN. 


tfl'' 


ilf 


I  liiid  tlio  huildcr  piil  in  a  liirjrc  rxini  wati-r-piui,  rijrlit  in  tlio  I'lirnaco- 
wall  aiul  alxivc  tlic  coal  sliiitf.  Tliis  cvaporatctl  nearly  three  times 
as  mueli  water  jter  day  as  did  the  first  mie;  and  the  two  toiffther 
made  the  h(iii>e  a  i^i'eat  deal  ukhc  eoinl'nrlalde.  Of  enur>e,  eare  had 
te.  he  taken  aijainsl  too  alii'ii|it  ehanufes  t^i  tem|iei'at  lire  in  liunishiiiu 
llie    \alei'-su|t|ily. 

Symptomatology.  The  eailie>t  symplnm  nf  iias(i-|)haryML;-eaI 
catarrh  is  ihe  |ire>enee  of  >nnielliiiiL:-  in  ihe  ii|i|ier  narl  nl'  the  iliioal. 
accnm|.aiiied  liy  a  (h'<ire  or  im|iiilse  le  n  move  it  'I'hi'  di-ehai\i^'e  w  liidi 
ha\\l\iiiL;'  hrin_;>  aua\    is  dl'  a   mere  or   le>>   miicd-puriilenl    character. 


vcllew  in  cnliir,  and  tcnaeiniis  in  cnn^i.-lciK 


leh    liV  the  IKlllelit 


to  he  huiu-cd  hcliind  llie  ])alatc;  ami.  wlien  tlie  disease  is  n|'  hm^'  sland- 
in_L:\  (|nitc  i're(|iienlly  the  im>st  |iersi<lent  ell'nrts  will  tail  to  ell'ect  a 
complete  i'enio\al. 

(hie  el'  liie  eomiiioii  symptoms  is  ilic  sn-callid  ■"diiippiiiL:"'  which 
flic  patient  feels  ill  the  throat.  Of  course,  the  term  "droppim^""  is 
lai^Li'i'ly  a  misnomer.  The  dischar,i;('  is  often  too  thick  and  tcnacion> 
to  di'op.  Another  thinu'.  it  is  n(M  located  so  niiich  upon  the  palate 
as  oti  the  posl-pharynii'cal  wall :  and  it  is  the  constant  desire  to  -wallow, 
which  its  presence  prodiici's,  that  irives  ri>e  to  the  mistaken  idea. 

In  tiiis  distant'  the  throat  is  easily  fatii;aied.  .\  feeling'  of  con- 
striction and  e\en  of  achinir  is  e\pericm-ed.  The  discharge  varies 
nuich  in  den>ity.  Sometimes  it  consist.-  almost  fiitirely  of  sero-pns 
and  trickles  (low  n  over  the  pharynx  and  olT  the  palate  easily.  In  others 
it  is  so  ti'iiacions  that  it  canmit  even  he  washed  away,  hiit  rctpiire.-  tlie 
manipnlal  ion  of  a  cottoiidiolder  to  remove   it. 

AlthoiiLiii  the  (liscliarL;'e  may  lie  constant,  day  and  ni^hl.  the  move- 
ments of  the  pharynx,  tou'ctlicr  with  elTorls  to  tdcanse  the  throat,  may 
keep  the  parts  free  hy  day-time:  hut  diirini;'  the  loiiii-  hours  of  sleep 
tlie  <leposii  aecumulatcs,  to  lie  removed  with  iliniciilty  in  the  momiiiL:. 

Sometimes  the  l-"iistachian  cartilaucs  are  swollen  ami  I'cd,  and  the 
(H'ifiees  (d'  the  tiiiics  hlocked  hy  secret  iiui.  If  this  extends  deepiv  into 
th(»  tuhes.  catarrh  id'  the  middle  cai'  and  dcafm^ss  may  result. 

In  children.  iidlammatiUT  thickcidnu'  td'  the  iilands  may  indiioe 
adenoid  disease,  with  moidh-hreatliing  and  all  the  other  symptoms 
produced   hy  nasal  stenosis. 

I'erhaps  no  class  of  people  feel  the  etVects  id'  this  disease  so  se- 
verely as  voice-users;  and  of  these  prohahly  cler,<rymen  are  the  most 
mimerons.  as  they  s|)eak  for  loni,'  jieriods  at  a  stretch  more  n^unlarly 
than  any  other  class  of  speakers. 


N.\S(i-l'll.\KVN(ii;.\l,    I'A  rAIilUI. 


lit!) 


1 


Diagnosis.  Altlioiijiii  thcrt'  is  little  diiliriilty  in  tliscovcriiii,'  tlu' 
|ir('si'iiii'  of  ii  |)(i>l-ilimiil  (lisi'liiir;;i',  citlici'  in  llic  (ir()-|ilijirvn.\  nr  n;isn- 
I'liiiniix,  vet  liicic  luiiy  lie  considcriililc  (lilliciilty  in  diiii^niosinu  tlic 
( iui,-c  nl'  its  (iccniTi'inc.  'I'll  lie  sure  tliiit  it  is  imicly  n;i-(i-|ili;ii\  iii;i'iil. 
I  111'  i'\(lii.-i(in  (if  ji  ii;i>al  vau-v  will  \>v  nccrssary.  Many  inso  of  pliaryn- 
".fal  ilisciiar^i'  aii>f  fi'oni  na.-al  olistrnction  or  Ic-ion,  cvm  ulu'n  tin' 
I  liaryn^i'al  l()n>il  i.-  liy|icilio|iliic;  and.  when  alro|iliir  I'iiinitis  exists, 
llio  throat  all't'ctioii  is,  in  ncai'ly  all  ca.-fs,  MTondary.  Ww  sanii'  may 
III'  said  of  nasal   |iiily|ius. 

If.  hnwi'MT.  \vi'  can  rxilmlr  tlic  \arions  aiVrrtion.-  of  the  no.-c.  and 
lind  till'  ulandnlai'  ti>~n('  in  the  llii'oat  cnatrd  with  scc'Tt  imi.  instead 
iif  lu'in.u'  clear,  nioi-i,  and  of  it-  natural  pinkish-i-cd  color,  the  ca.-e  i- 
clearly  one  of  |diai'ynu.  .li  oi'i.irin.  When  Luschka".-.  or,  a.-  it  is  sonic- 
linies  called,  'roiiiwaldl 's,  lmi>iti~  lias  oci  nrred.  liic  dischai'L;e  will  he 
more  [inrulent  than  in  othei'  varii  lies  of  ihe  di-ejise;  and  in  the  centre 
<'(  the  \aidl.  alio\e  the  |ii'oiniiience  of  the  atla-.  will  he  Men  tlu'  pro- 

jecl  in,li'   '^''f- 

'The  possihility  of  niislakini;-  syphili>  (d'  the  na>o-pharyn\  should 
he  avoided  hy  exclusion.  In  douhtful  ea.-es  a  course  ol  s|)ccitic  trcat- 
luent  should  he  ti'ied. 

Prognosis.  When  taken  early  and  clii-onicitv  ha.-  not  liad  time 
to  he  thorou^^'hly  estahlished.  it  is  usually  anienahle  to  ireatnicut;  hut 
it  is  not.  a  disease  that  has  any  tendency  toward  .-poniaiieous  cni'c. 
W  hen  it  has  heen  lon.i;'  in  existence,  and  lias  heconie  e>-ent  tally  chronic, 
althoiiLih  much  can  he  done  t'or  it.  positive  and  pi'rmaiient  cui'c  need 
not  he  expected.  In  cases.  howe\ei'.  when  it  i-  pui'el\  a  sceoiidaiy 
nll'ei't  ion,  the  removal  of  ihc  pi'ini.-iry  cause  should  always  he  followed 
iiy  cure. 

One  tlilliculty  the  phy.-uian  has  to  contend  with  in  dealiuL;'  with 
these  cases  is  the  ,i,^'iieral  nnw  illimiiiess  of  patient-  to  >uhiuit  t^  a 
hui;.^'  coiii'se  of  treatment  fm-  what  they  often  con-ider  a  eompaiat  i\  dy 
ninmpoitant  disease. 

Treatment.-  Whatever  may  havt^  heen  the  origin  of  the  all\'clion. 
or  the  prcdisposiiiy-  cause  which  tended  toward  its  development,  it  is 
essentially  local  in  its  manifotat  ions.  Ilciiee  the  lii'.-t  ohjecl  of  treat- 
ment should  he  to  -ecure  peifeet  (deaiiliness  (d'  the  part-;  all'ccteil.  This 
can  usually  hi'  accoin])lislied  hy  the  use  of  certain  alkaline  waslies 
The  leniiieralure  of  tlic  solution  should  always  he  ahoiit  1(10°   l'\ 

In  order  of  merit  the  i'ollowini:  will  serve  as  illiistrations:-- 


S 


'4^)0  i»isr,.\si;s  (»i-  Tin:  I'JIahvw. 

1.  li   S.ul.   l.icarh 8 

Sod.   bibor 8 

Acid,  ciirl.dl 2 

(ilscciiii    15 

.\(|iiimi     ad   ;tOO 

M. 

2.  li    Snd.   fhlnii,! 8 


.\i|uaiii     iid  ;t(10l 


M. 


;!.    li  .\cidi  iMiiici   12: 

(ilyci'riii 8 

A(|iiiiiii   iui  ;joo. 


.     8 

.  ;ioo 


I.      li    I'dt.  flil'ir 

A(|iiani  bullifiit 

M. 

Tlic  best  iiicllidd  (if  applyirifj  the  i^oliitioii  is  by  thi'  use  of  a  post- 
nasal spray-syrinue  (Fiir.  •"><')•  I'l  usinif  the  iiistniniont,  after  insert- 
ing tlie  hard-rubber  end  l)eliin(l  the  palate,  the  head  shoiikl  be  bent 
forward  over  a  bowl.  Then  tlie  llnid  is  foreed  tliroiigh  the  naso- 
jiharynx  and  the  nasal  passatrcs,  coming  out,  in  great  measure,  through 
the  anterior  narcs.  By  this  metliod  both  the  vault  and  the  nasal 
fossae  are  elTeotually  cleansed.  The  position  of  the  head  referred  to  is 
important,  when  a  continuous  stream  is  thrown  through  the  passages, 
as  otherwise  part  of  th(^  fluid  would  find  its  way  into  the  laryn.v.  When, 
however,  the  interrujited  flow  is  used,  the  bulb  being  filled  separately 
each  time,  this  precaution  is  not  necessary. 

This  method  of  treatment  should  be  followed  twice  a  day  at  first. 
When  improvement  has  become  marked,  the  interval  between  treat- 


Ti   Slid,  liiciuli 3ij. 

S(><1.  bibov 3i.j. 

Ac.  carbnl 3sa. 

(Jlyreriii 3iv. 

Aquam    lid  Jx. 

Sod.  r]il(iri<l    3ij. 

Aiiuaiu    ad  3\- 

Acidi  borici 3iij. 

(ilyccrin 3ij. 

Aquam    ad  Jx. 

Tot.  chlor 3ij. 

Aquam  bullicut Sx. 


M. 

n 
II 

M. 
R 

M. 


Kr'' 


li 


NASU-l'ilAUYNUEAL   CATAIIHII, 


'-iOl 


niciits  iiKiy  l)t'  li  nu'tliciicd  tn  suit  tln'  r('([iiir('iiit'nts  of  ciich  ciisc.  If 
from  acuto  Fonsitivcti' --  ol'  tlio  parts  llic  Hiiid  used  slioiiM  prove  to 
lie  too  irritating',  it  ruiild  l)i'  wciikcm'd  In  linli'-strciiLTth  or  even  loss. 
In  sonu'  cases  diiriiii,^  early  treatmeiils  a  weak  soliitimi  id'  eoi-aiiie  mi'^dit 
require  to  he  applied,  lnit  oiiiy  under  l!ie  doetorV  siipervi.-inii. 

Soiiu'tiiiies  even  this  vij^orous  treatment  may  not  cUVetually  re- 
move the  tenacious  eoatiii<:;  and  a  curved  cotton-lioldei'.  jiassed  up 
lichind  the  ])alate,  guided  by  the  post-rhi:ial  mirror,  may  lie  reiiuired 
to  moj>  it  away. 

Ilaviiiir  thoroiiLihly  cleansed  the  naso-pliarynx,  stiinuhitinu'  and 
astringent  treatment  of  tlie  diseased  miK'osa  is  tlieii  re(|uiri'd,  ami 
probahly  for  this  purpose  no  application  is  sn  useful  as  that  of  l(i- 
per-cent.  solution  of  nitrate  <if  silver.  It  shoidd  he  applied  by  means 
of  a  curved  cotton-holder.  It  has  an  astriiiiieut  elTeet  updU  the  dis- 
eased surface-epithelium,  and  at  the  same  time  appears  to  check  pus- 
cell  ])roliferation. 

The  following  tannin  pigment  lias  also  a  good  efTect  applied  in 
the  same  way: — 

1.     R   Afidi  taniiici    1|5 

Glycerin 31 

A(iuam     ad  .'30| 

M. 

Of  sprays,  after  ollicc-treatment,  to  be  used  by  the  patient,  I  have 
found  nothing  better  than  the  following  applied  by  atomizer  through 
the  nose,  and  in  suitable  cases  into  the  post-nasal  pharynx,  by  means 
of  the  curved  tip,  two  or  three  times  a  day: — • 


i-i 


i  V]  i 


111 


2.     R  Tliymol    

Mentliol    

Albolene    CO 

M. 

.•\nv  of  the  following  would  also  answer:— 


1.  It   Aridi  tannici   {rr.  xxij. 

Glvf'orin wixlv. 

Aqiiaiii    ad  5j. 

M. 

2.  IJ  Thymol    pr.  iij. 

Mpiitliol    frr.  X. 

Albolene    S'j, 

M. 


'■ '  1 

1 

■  :        ■       i 

H:  1 

j 

1 

1 

11 

,\-< 


fiii 


205J  iJlSKASKS    OF    TlllO    I'llAIlYNX. 

1 .  H   Kiicalypt  1)1    21 

Mfiitliul     15 

All)olcllr    (i() 

M. 

2.  H  Crcasolc lO 

Ol.  iiii'iitli.  pip lU 

.\ll)(il<'iic     tiOl 

M. 

.'i.      U    I'nrimiliii   41 

.\i|iiniii     ad  00; 

M. 

4.      H    Ilydni^fcii  iicioxiilc  12| 

.\i|Uaiii     a>l   (ill' 

M. 

^\  livii  llii'  nns()-pli;ii\  ii;it'iil  ,L;liin<l.-  nvr  liiliii'ucd,  and  cdiitiiiin' 
^;l't•^('tln,li■  pus  with  liltic  ])i'ii>|n'cl  nl'  iiiiiiroNriiicin,  the  rnnoxal  or  dc- 
stniction  (iT  .iiliiiid-tissiio  Ix'coiiu'S  lU'ccssaiT.  'I  o  a((niii|i|ish  Uiis  vari- 
ous Mutliods  lia\('  laH'ii  devised.  Auioiil;'  the  niiinla'i'  is  the  use  nt  the 
galvaiuK'auh  TV.  'This  can  lif  done,  alter  apiilvini:  a  l--)-pei-eeiit.  solu- 
tion ol'  cocaine,  li_v  pas-inir  the  electrode  directiv  hackwai'd  tlu'onL;li 
the  nose,  the  (jperation  hein.ii'  .yiiided  hy  the  post-rhinal  minor,  it 
can  also  he  accomplished  hy  the  curved  post-ihinal  oloolrode,  passed 
throuuh  the  mouth  and  up  behind  the  palate.  i;uidcd.  as  Ijcfore,  hy 
the  u.-e  (d'  the  mirror,  in  the  latlei'  meihod  the  proteelioii  of  the  soft 
])alati'  is  an  iinpuManl  cnnsidei'alion. 

'I'hi-  can  he  acconiplishe<l  in  two  ways:  either  liy  the  use  of  a  well- 
chosen  palate-rctractipr  or  hy  the  u>v  of  ruiiher  cords  passed  throu.uh 
tlie  narcs  and  out  thrcuiLih  the  niouth.  the  two  ends  hein^'  lied  on  cacli 
side  over  the  lip. 

("ascs  occur  in  which  it  is  impossihic  even  to  examine  the  post- 

1 .  R   Fdcal ypl  ol    Sss. 

Menthol    jrr.  viij. 

Ailiiilt'iic    ,^ij. 

\\. 

2.  \i.  Cicasofo     mx. 

(>|    inciitli.   ]ii]> iiiK. 

.Ml)()l('in'    ,^ij. 

M 

.'?.     H   I'onnalin    Sj. 

.\(|iiam    ad  Ji j. 

4.     IJ   lIy<lro<;i'n    peroxide    3iij. 

.\(iuaiii    ad  Sij. 

M. 


i 


NA>t>-niAitVN(;i;Ai.  (  \  i  akuii. 


.'U3 


|iliiinii\  williiiiit  llic  ii.-c  1)1'  ii  iiiilali'-rftiactiir;  Iml.  riuliiiiiiti'ly,  tliu 
iiiiijority  (if  |iiiti('iil>  ciiii  lie  triiiiicd  t(i  (•niili<i|  the  piihiti-iiiiisclos  8iit'- 
liciciit  tor  this  |iiir|i()st'. 

I  liclicNC.  however,  tliat  the  ln.-i  nuthoil  nl'  ii'iiioN  iii^  iht'-.c  post- 
toi:>illai'  ciihir.^ciiiciil,^  i>  li_v  the  ii.-r  ol'  ( Jn|  t>l(iirs  ciiictlc-.  \\\  two 
or  thrcr  sutTps  of  thr  in^liuiiinit  the  (li>ca^('(l  ti.->ih'  ran  Ik'  iTiimvi'd 
and  a  smooth  surface  left  in  it.-  placi'. 

Sometiiiics  ehroiiiie  aeid  i-  n>e(l  a-  a  eaiistie  instead  of  the  Ltalvano- 
eantery.  Imt.  like  this  inst riinuiit.  it  i-  lii<el_v  to  injni-e  lualtliy  tis^Me, 
except  under  the  iHost  cai'eful  manipulation.  I'.oth.  too.  are  tedious, 
reipiirin^'  a  se|-ie.-  of  operation.-,  to  cllVct   the  de-ii'ed   result. 

As  a  distinct  variety  of  iia>o-pliar\  n,L;eal  eatai'rh.  the  atrophic 
type  miu'lit  lie  mcnlioiU'd.  Jt  is  d(Uilitful,  howevci'.  if  ii  ever  occurs 
except  as  a  re-ult  and  continuation  of  at  I'ophic  rhiniii.-.  It  i>  produced 
hy  the  ^-anie  cause,  and  lias  e»entially  the  same  patliolo:^y.  dia.irnosis, 
and  pi'oiriiosis.  Left  to  itself,  it  is  ju-t  a.-  hopele.--  of  amelinration  or 
euro,  while  it  demands,  ami  i>  ecjually  anu'iiahlc  to.  a  similar  line  of 
troatnieiit — a  speedy  oi'  ])0<itive  cure  heinij  impos.-ihle,  while  ameliora- 
tion of  symptoms  and  a  fair  deixrei'  (d'  comfort  can  alway.-  I htaincd. 

When  Toniwaldt's  disea.-e  or  inllammation  of  the  .-o-callcd  pharyn- 
.^eal  bursa  exists,  free  incision,  with  suiiseipieni  anti-eplic  treatment, 
will  often  be  followed  by  a  jjood  result. 


Hi 


ai 


■  !' 

,"     i     i 


CIIAT'IKU  XX.W  111. 


ADKNoll)  (;|;n\\ll|S  OF  'l  ||K  NASO  I'll  \l;VN\. 


I 


l'(»>r-i'ii  \  i;v\(;i: Ai.  adt  iiui(I>  nir  n\ci  l:iw\mIi-  ni'  alitioniial  ilovel- 
(i|itii('iits  (if  llic  l\  Miplhiid  tissiKs  which  cxi-t  iiatiiinliy  during  enrly 
life  ill  ihi'  naxi-pharviiv.  Wilhrjin  Meyer  ua.-  the  tiisl  to  study  tlu' 
lii>tory  of  these  vcLidat inns  lh<ii'(Ui<4lily;  and  he  ha>ed  iiis  coiKdusioii:* 
upon  the  jieisoiinl  mid  ciiiLdtil  invcstiLriitidii  (d'  nver  one  Inindrcd  cases. 
iS'unu'i'ous  writers  have  written  extensively  upon  the  suhjt'et  since 
Jfeyer's  first  ])aper  appenred,  hut  tliey  liave  added,  comparatively 
speaking,  little  tn  wjiat  he  had  already  given  us  ([•'igs.  fA  and  ?3«). 


l''i;r.  T.'i.     liifniitJc  aclciieid^.     V'v^.  T.'f"  icincscnN  a   irrnwlh 
i|iiit('  ciiiiiiiioii.     (After  SclKullf. ) 


t  . 


i 


u\h 


Adenoid  growths  are  found  i'l  tlie  upper  and  back  part  of  the 
naso-pharynx.  on  the  site  of  the  piiaryngeal,  or  FiUsclika's,  tonsil.  The 
situation  is  hetween  the  orifices  of  the  Eustacliian  tiihes.  hut  behind 
and  ahove  them.  Tn  some  cases  they  grow  so  large  as  to  press  upon 
these  tubes,  even  overla]iping  their  orifices,  and  preventing  the  proper 
action  of  the  tubal  muscles  (l''ig.  71). 

Pathology.  —  Between  infantile  and  adult  life,  the  pathological 
conditions  of  adenoid  disease  vary  very  much.    Tn  the  former  the  sur- 
face of  the  adenoid  enlarixenicnt  presents  a  convoluted  appearance,  of 
(204) 


SASU-I'll  \liV\\.       AliKSulliS. 


•.'iir, 


titraw  lifiiT-likc  ("iiitiiiir,  the  iini|ii|r>  .■-IjiiiiliiiL:'  mit  n\(i-  tlic  wlmlc  siir- 
fiici',  cxcciil  wlicii  l.ii»clil\ir.s  file  is  |iri'-('nl;  llidi  the  (ciitriil  poitioii 
will  ('xliil)it  a  iiiarkiil  pinjtctinii,  In  ilir  lalirr  tlir  l\  in|iliatic  ct'll- 
I'lciiicnts  lia\i'  uiMii  platr,  in  soiiir  iiifa^iin',  \i>  I'limirctivr-tissiU'  rnriua- 
tion,  iuul  a  dciiMr  jiml  ^tiinoilirr  (lc\i'lu|iiii(iit  iMciipir*  the  pdsitinii  u|' 
the  (iri;:iiial  ailiiiniil  .-inul  iiif.  In  ihr  iransitinii-pcridd  k\'  life  tlir 
l()ii>illai'  li\  pelt  injiliy  will  alMi  indicalc  a   lilrinlinu  >>\  the  iwn  types. 

Itl  ynlin^cllililicn   In   t  III'  Idllrll    II    I-  alnici«l    like   t  hr  -dfl  nc.-s  n|'  rcITlll'al 

(is-iic. 

MiiTd'^cMpirally  llii'  -nifacr  i-  cdvcnil  wiih  tnlnnmar  ciliatt'd  cpi- 
tlicliiiin,  Init  llic  cilia  arr  iVcipicnl  ly  lirnktn  and  linii  and  in  sonic  in- 
stiUK'cs  ali>cni.  I'lcm^alh  lliis  \\c  lia,\i'  tlic  niy\dniat(iiis  niucnsa  llllcil 
with  lynipli-ciiijin,-clc<  iind  tlic  idiiuil  lynipli-luliiclc^.  separated   froni 


■r\ 


II 


Fig.   74.     Stiiliulitt'  forms.      (Alter  Sdiaillc) 


the 
Tlio 
lind 
lion 
pper 


Ilea 


piir- 
of 


cacli  otiicr  liy  inlci-rolliciilar  iract,-  (I-'i'j.  '•'>).  It  is  essentially  a  lym- 
phoid stnicturi',  copiously  sujiplied  with  lilood-vessels,  (he  wh<de  boiiiii' 
arranged  in  the  form  of  lobule.s  (and  secret injjr  mucus  ny  lymph  from 
the  crypts  1)etween  the  follicles).  As  the  aileiioiil  hccomes  old  with 
increasinir  years,  tli'^  lyinpli-tis>ui's  hccome  ahsdriied.  often  slii'inkin.i,^ 
away  hy  the  (Ifteeiilh  (u-  the  twentieth  year.  In  other  instanc(>s  hyper- 
plasia takes  tlie  jilace  of  alisorptitm,  and  fibrons  connective  tissue  de- 
velops arnonif  tlie  follicles  and  lohules  of  the  adenoid. 

'rii(>  .ireneral  im])r<v-ion.  founded  on  clinical  experience,  is  that 
the  rd)rous,  connective-tissue  element  vai'ics  in  dii'cct  ratii>  with  the 
aae  of  the  ])aticnt.  ^Icliride,  in  his  recent  W(uk,  takes  issu(^  with  this 
idea.  Fonndinij  liis  opinion  upon  tlie  examination  of  six  hnndrju 
eases  of  adenoid  disease,  he  savs:    "Tliat  wliile  in  manv  cases  there  is 


)   ■ 

■ 

t 

i 

20G 


DISKASIJS    OF   THE    I'HAUYNX. 


a  tondoiicv  to  iiicica.-i'  ol'  tlif  (ihroiis  oloment  at  tlie  oxpen^^e  of  the 
cellular,  yet  it  is  a  iiiistakrii  idea  to  bolic've  that  it  tfiids  to  eoiiie  on 
ni  any  ^nveii  a^o,  and  that  it  is  mori!  (-'0111111011  in  the  very  younii'  eliild 
than  in  the  adult." 

Together  with  adenoid  development,  there  are  often,  |)roliai)ly  as 
an  ell'ort  ol'  extension,  chains  or  clusters  ol'  enlaryed  follicles  extend- 
ing- down  the  sides  of  the  oro-pharynx,  and  situated  behind  the  poste- 


I 


Fig.  75. — Microsc()])itiil  section  of  hypertrophiod  jiluiryngeal  tonsil 
with  lynii)hoid  infiltration  (20  diainoters).  fl,  Lymphoid  follicle,  h,  Strati- 
fied squamous  epithelium  of  tonsillar  cryjit,  infiltrated  with  lymphoid  cells. 
c,  Cavity  of  crypt  filled  with  secretion  and  lymphoid  cells.  (Author's 
specimen  by  Bensley.) 


ill 


Tior  pillars  of  the  fauces,  while  sinj^fle  ones  may  be  scattered  here  and 
there  over  the  post-pharyiifjeal  wall. 

Etiology. — Thi.s  is  not  believed  to  be  a  disease  of  early  infantile 
life.  Very  few  cases  occur  during  the  first  two  years.  The  exanthem- 
ata usually  attack  cliildren  after  that  age  has  been  reached,  and  it 
is  to  the  effects  of  those  diseases  that  many  cases  can  be  traced.    Bar- 


; 


Li- 
ps, 
r'a 


land 

Itilo 
3Tn- 
it 


NASO-PHAUYNX.      ADEXOIDS. 


•.'o; 


rctt  and  Wi'hstcr,  of  .Mclljoiinic,  hclic'vo  tliat  scarlot  IVvcr,  mcaslos. 
di|)litliiTin.  and  \\iiiMi|)ini,'--c()iii,di  haxr  a  directly-causal  relation  to 
adenoid  development.  Iiasinir  their  theory  upon  the  natural  tendency 
to  lymphoid  development  manil'i'sled  iiy  children  ahoul  the  period  ol' 
the  ~ei'oiiil  ileiitition. 

'I'hc  lar^c-t  |iei'centaL;'e  of  i^ases  occur  hetween  the  aires  of  five  and 
fifteen  years. 

(ii'c\ille  .Macdonald's  iilni  that  one  prominent  cause  in  youm;" 
chililii'n  is  the  procnee  of  anterior  na^al  >teno>i.--.  the  cH'cct  heini;- 
to  lowci'  iiai'oniel ric  pre>>ui'e  in  ilie  na>o-;)haiyu\  and  to  pi-oducc  hy- 
j)era'niia  Ihere.  appeai>  in  .Vmei'ica  to  he  nntenalile.  in  my  own  e\- 
])eri<'nce.  I  haxc  found  nasal  stenosis  in  yonnu'  children  /h'i'  si'  e\cee<l- 
ingly  laiH'.  Where  I  have  seen  it  the  cause  has  almost  invariahly  i)een 
Iranmatic.  Kveii  whei'e  the  nostril-  have  heen  lilocked  with  niucus. 
adenoids  iieimi'  present,  clearinti'  the  pas>a,;;es  has  reveale(l  patt'Ut  nos- 
trils: (piite  sullicienllx'  open,  after  the  adetioids  hail  heen  I'cmoved.  to 
permit  of  noiinal  respii'at  i(Ui.  Instead  of  ol)stru(tion  and  disease  of 
the  nasal  passa.ii'e-  iieinii'  the  cause  of  a(h'noi(l  enlaru'cment  in  yoiin^" 
cliildreii.  1  helieve  the  I'cvei'se  to  he  the  case,  and  that  not  infre(iiiently 
hoth  ]iuru!ent  and  atrojihic  I'hinitis  owe  their  oi'iiz'in  (hrectly  to  the 
enlaiLienieiit   of  the  so-called   Luschka  tonsil. 

Jleredity  is  not  without  its  inlluence  in  etioloLiy.  for  fretpu'ntly 
several  mendiers  of  the  sann'  fannly  will  successively  apply  for  treat- 
ment for  the  same  diseaM'. 

The  compai'ativc  frecpieiicy  in  males  and  female-;  varies  little. 

It  is  fre(piently  associateil  with  the  presence  of  hypertrophied 
1'atu-ial  tonsils.  ])rohahly  indicatin.u'  the  existence  of  a  strumous  diathe- 
sis, with  a  tendency  to  .duiormal  lymphoid  (h'velopment. 

Symptomatology. — The  symptinns  may  he  divided  into  aural  and 
gi'iieral.  Of  the  two  classes,  the  aui'al  are  the  most  important.  Thi- 
importance  lies  in  the  fact  that  when  auial  symptoms  do  appeal'  they 
indicate  no  little  dan,ii'er  to  a  very  important  ori;an.  In  the  Iani;'ua,i:'e 
of  Pymhon.  "Deaf-nudism  is  prohahly  more  often  due  to  ailenoid 
hypertrophy  tlian  to  any  other  siuLiie  caus(\  the  hypertropliy  havin,ir 
occurred  Ixdore  the  child  has  learned  to  speak." 

The  lirsl  >ympt(un  of  ear  irouhle  is  the  presence  of  nu>re  cu'  less 
deafness,  caused  hy  the  closure  or  ohstriiction  of  the  I'histaehian  tube 
This  may  he  followed  hy  tinnitus  aurinm.  otitis  meilia,  and  abscess, 
residtinjj' in  perfoiali<ui.     Ilealinc:  may  then  lake  place;  l)ut  freiinently 
ehronjp  otitis  media  puruleida  nMnains  foi'  weeks  or  months  and  <  von 


1 

I 
I 


:!| 


i 

m 


1 1 

;    I 


>?  |. 


i!    I 


■'  r 


208 


DISEASES    OF   THE    ]'1IAI{YNX. 


'«'■ 


years  without  iK'aliii,!;',  ii'  the  adcnoitls,  the  cause  of  the  abscess,  arc  not 
removed.  When  liealing  of  the  otitis  does  oeeur  witlioiit  acU'imid  op- 
eration, tlie  continuance  of  pressure  and  the  extension  of  catarrli  to 
tlie  ]uistac]iian  tul)e,  ])rodiiced  1)V  tlie  evcr-))rcsent  liypertr(i])hy,  may 
lead  to  renewal  of  the  inlhimmalory  attack  at  any  lime. 

If  the  dcveh)pnient  of  the  adenoids  is  uneven,  tiic  growth  licing 
in  juxtaposition  with  (me  tuhe  and  not  tlie  other,  it  is  (jiiile  ])o,-sihle 
for  one-sided  deafness  to  exist  for  years,  and  the  liearing  |)ower  to  liave 
diminished  one-lialf,  witliout  having  l)een  discovered.  'J'he  evil  ed'ect 
of  tiic  ])rescnce  of  adenoids  upon  hearing  is  chielly  ])roduced  in  early 
life,  although  the  stenosis  and  general  shrinkage  which  occur  in  ma- 
turity may  lemoxe  all  intt'i'fci'i'nce  with  the  Eustachian  tid)es;  yet  the 
evil  may  already  have  heeii  accomplished,  and  the  sense  of  liearing  may 
have  become  permanently  impaired.  Still,  many  cases  do  occur  in 
which  ear-symptoms  arc  never  develo])ed. 

General  )S!/iii/iloiiis.- — Jn  young  children  the  most  pronoui;c  d 
symptom  is  continuous  nmuth-breathing,  with  discharge  (d'  yellowisi; 
muco-pus  from  both  anterior  and  ])osterior  nares,  the  source  of  the 
secretion  being  chielly  the  cry[)ts  and  follicles  of  the  hypcrtrophied 
adenoid  tissue.  The  presence  of  the  growth,  together  with  the  accu- 
mulated secretion,  seriously  interferes  with  nasal  respiration.  'i"he 
child  has  neithei'  the  kuowh'dge  nor  the  ahility  to  tlii'ow  olf  the  dis- 
charge, and  it  simply  trickles  away.  When  the  ])hai'yngt'al  tonsil  is 
only  moderately  enlarged  there  is  still  room  for  nasal  breathing  during 
the  day.  'I'he  anteri(n'  nares  nuiy  be  free  from  secretion:  but  the  ro))y 
nuicus  still  ]U'esents  it>elf  in  the  thi'oat,  and  on  going  to  sleep  the 
nunitli  drojis  open.  The  night  pa-ses  with  stertorous,  disturbed  breath- 
ing, accompanied  by  ti^etrulness  and  dreaming,  and  in  the  morning  the 
little  patient  wakes  nj)  tired  and  uni'cfi'eslied. 

One  symptom  which  is  always  pre~eut.  when  stenosis  occurs  as  a 
result  of  the  obstruction,  i-  what  .Meyer  calls  '■(he  ilead  voice."'  The 
lone  undeigoes  a  change.  The  r(  sunance  of  the  voice  is  d.  ii'o\ed,  bv 
licing  cut  olV  trnm  the  resonating  chainlicr.  Iii>tead  of  what  is  com- 
moidy  called  the  "nasal  twang"  being  produced,  it  is  abolished.  The 
vocal  wave>  are  inti'rl'ered  with,  and  the  pro))er  voice  is,  in  a  sense, 
smothered,  thc'  power  of  correct  singing  being  entirely  destroyed. 

When  the  nasal  pasMiges  are  free  and  t)u^  breathing  nornud.  mas- 
tication and  deglutition  do  not  inlerl'ere  in  any  way  with  respiration; 
l)ul,  when  the  naso-phai'yngeal  stenrwis  is  severe,  the  act  of  eating  be- 
comes a  ili>tressiui;'  thiuu'  foi'  the  little  sull'erer. 


■<ij 


lis  a 

lu; 

l.v 
un- 

lie 
use, 

IlilS- 

|()ir, 

1.0- 


.NASO-l'lIAlfV.NX.       ADKNOli)?^. 


■J<);» 


Kxteriial  ilrroniiitii's  of  tlic  face  and  clicsl  arv  also  the  result  of 
j)ri)|(iii^e(l  adciidiil  ili>('as('.  ( ilcitsiiianii  lias  [.dinted  out  the  inlluriiee 
of  aci'MKiids  u\>i\]]  the  dcvi'ldpinciit  ami  (•(inli;^iiiatinn  of  the  nasal  sep- 
tum and  upper  maxilla.  Many  facial  defminities.  he  .-ay.-,  aic  produced 
hy  their  iuteiiVreiuc  \\ilii  nasal  I'espii'atitui,  sueh  a.~  hiiih-arched  palate, 
^'-sllape(l  upper  maxilla,  with  the  latei'al  teeth  tiii'iied  inwai'dly.  and 
the  molars  out\var<lly.  As  a  loult.  the  upper  jaw.  heim;-  llatteiied, 
projects  ))ointedly  forwaid. 

De  Havilland  Hall  lay^  emphasis  nprni  the  amount  of  ehcst-de- 
I'onnity  produced  hy  (h'fective  nasal  respiral  inn.  This  in  early  life, 
ho  says,  is  alnu)>t  alway>  (lecasioneil  hy  the  pri'seiice  of  adenoid  ve,i;eia- 
tions. 

The  reflex  inlluenees  of  adcunid  enlarucmi'iits  olVer  a  wide  held 
for  investigation,  l^ven  over  the  voluntary  movements  of  the  young 
child  their  eil'ects  have  been  notieeil.  Leiiiiox  IJrowne  and  Uiwson 
Delavan  have  each  of  them  I'elated  the  hi.-ioiy  of  a  ease  of  masturhation 
in  a  young  child  troubled  with  adenoid  disease;  and  in  each  case  re- 
moval of  tho  growth  was  followed,  without  any  further  interference, 
by  cessation  of  tho  habit. 

Headache  is  oftert  the  result  of  adenoid  picssure:  and  instances 
of  asthma,  lai'yngeal  c(Uigh.  and  hay  fever  havi'  all  been  relieve<l  by  the 
removal  of  tho  growth. 

Otto  gives  the  histiuT  of  a  remarkable  case  of  a  young  lady,  aged 
is.  who  was  completely  <iii'ed  (d'  enuresis  noctnina  by  extirpation  of 
a  mass  of  adenoids  located  in  her  miso-pharynx. 

One  other  point  in  reference  to  symptonis  should  be  uu'Utioned 
here.  In  the  most  sevei'e  cases  of  adenoid  cidarg(  uieul  a  ciuidition 
termed  aprosexia  is  freijuently  developed.  In  other  words,  the  dull- 
ness ami  menial  apathy  indicated  by  the  open  nuuith  and  \innatural 
expression  of  featui'cs  has  its  countei'pai't  in  the  nu'Utal  e<indition  (d" 
the  jiatienl.  'I'his  is  evideiu'cd  by  iri'itabilily  of  tempei'.  incapacity  of 
concentration,  and  deiicieucy  of  memory.  That  the  lueutal  power  of 
the  brain  is  not  itself  injured,  except  by  temporary  suspension,  is 
])roved  by  the  complete  change  of  both  facial  expression  and  mental 
activity  which  follows  the  removal  of  the  gi'owihs.  The  sulky  and 
cross  child  with  opi'U  moulh  will  he  Iran-formed  into  a  brigbl  aiul 
cheery  one  with  closed  lips  aiul  an  aptitude  bir  .-tudy  pre\iou>ly  un- 
known to  it.  'J'he  cause  of  this  lack  of  mental  grip  is  ascribed  to  the 
condition  of  lyin|)hatic  stagnali(m  at  the  bast'  id'  the  brain,  t^uail'e 
draws  attention  to  the  inuiu'rous  nnmde  foramimi  communicating  be- 


•*  :S 


!^  n 


4; 


■    1    , 

';   r 

ji 

s: 

h 

2M) 


i)isi;.\si:s  OK  ttik  nrAHYNX. 


twot'ii  the  iiasiil  |)iissii,i:'<'s  iind  the  cniiiiiil  cavily,  and  that  a  similar  nioii- 
tal  condilion  is  stuiR'tiiiK's  round  in  sevfre  cases  ol'  nasal  ])olypns. 

Diagnosis. — 'J'lic  faucial  symptoms,  nasal  stenosis,  open  inoutli, 
flatness  ol'  voiee.  toifc'tlior  with  the  eai'ly  life  of  the  patient  are  usually 
sullicient  to  ])roduce  a  correct  dia<iiiosis  without  a  rhinosco|)ic  or  digital 
examination,  'i'he  use  ol'  the  jiost-nasal  mirror  is  often  impossible  in 
children;  hut  examination  of  the  pharynx  hy  either  suidiyht  or  re- 
flected li,i:ht  will  often  revt'al  a  fullness  of  the  ])alale  or  the  reuion 
])e1iind  it  diaLinoslic  of  the  cause  of  ohstniction.  Digital  examination 
behind  the  ])alate,  however,  will  at  ont'c  render  the  diaji'nosis  possible. 
'J'lie  s(dt.  corrupited.  brain-liki'  tis.-ue  will  be  felt  to  present  itself  on 
the  postei'ioi'  and  upper  wail  of  (he  naso-pharynx:  a  condition  which 
in  early  life  '  nld  he  ])roduccd  by  no  other  abiKirnial  iirowth.  Some- 
times they  THiv  descend  into  the  oio-plinrynx  and  lie  visible  to 
direct  exaniinati' 

When  it  is  ])os.-ible  to  obtain  a  post-rhiiial  \  iew,  a  r(Uinded  (U' 
stalactite  or  llattened  nodular  tumor  will  be  ^(H^n  luin,iiiii,u'  down  froiu 
the  rooi' of  the  vault  and  |)rojecting  forward  from  its  posterior  surface 
(Fij;.  7'^).  Sometimes  it  hauii's  directly  downward,  hidiuii'  the  upper 
\r,\r{  of  the  posterior  nares  from  vii'W  ( l''i,g.  Tl).  When  very  larii'e.  the 
whole  of  the  choanal  may  be  covered. 

In  adult  life,  when  the  growth  is  present,  it  will  have  lost  its 
nianunillated  ajipearance, — at  least,  in  a  majority  of  instances.  It  is 
then  more  hyi)erplastic  in  character,  the  fibrous,  connective-tissue  ele- 
ments having,  in  large  measure,  taken  the  ])lace  of  the  lymphoid  and 
glandular.  The  consecpience  is  that  the  tonsil  is  denser  and  firmer, 
with  a  smoother  surface  and  containing  fewer  crevices  and  indentures. 

Prognosis. —  in  mild  cases,  insufficient  to  ])roduce  na<al  stenosis 
and  Kustachian  obstruction,  the  prognosis  even  witliout  treatnu'iit  is 
favorable,  as  Nature  favors  absorption  of  the  tonsillar  hypertrophy, 
when  puberty  and  adult  life  are  reached. 

In  many  cases  reipiiring  operative  treatment  the  proguosis  after 
removal  is  cijnally  good,  provided  ear-lesions  have  not  alreaily  oc- 
curred. Even  when  serious  ear-com])lications  do  exist  in  young  chil- 
dren, hope  may  be  expressed  of  arresting  the  progressive  deafness,  to- 
gether with  expectation  of  a  certain  amount  of  im]n'ovement.     When 

lict 


)sis,  we  mav  satelv  pre( 


the  ear  disease  has  stopped  short  of  necn 

the  arrest  of  chronic  otitis  media,  both  catarrhal  and  su^jpuralive,  at 

least  in  a  majority  of  cases. 


I? 


ecurrence  ( 


if  adenoids  after  removal  rarelv  occurs.     The  text- 


NASO-rilARYNX.       A  DKNOIUS. 


211 


) 


books  speak  very  li.ii:lilly  upon  tlic  subject.  Some  even  afTirni  that  after 
tbor()U<fh  al)Iati()ii  thev  never  return.  .Mthouirb  this  is  tbe  rule,  still 
many  in-iauees  liave  occurred  in  wliich,  after  thorou^^h  extirpation, 
there  has  beeu  a  re(Icvi'b)pinent  ot  the  jfrowtli.  Dehivan,  Wriylit, 
lUitts.  Meyer,  and  (itiicrs  have  rec(U(h'd  cases;  and  Hopkins  aives  the 
liistory  of  three  in  wliich,  after  couiph'tr  reumval.  a<ieuiiids  developed 
ajfain.  1  have  pi'i'sonally  atteiuh'd  two  cases  in  which  reciirreuce  took 
place  after  what  1  believed  to  be  IIhu'oiiuIi  removal. 

Alth(ni<rh  the  operations  for  the  removal  of  adenoids  are  usually 
attended  with  little  dan^iicr.  and  at  the  same  time  productive  id'  the 
best  results,  yet  in  some  instances  a  fatal  i.-sne  has  followed  the  opera- 
tion. Sandford  reports  the  death  of  a  child  six  hours  afterward  from 
convulsions;  ^Fayo  Collier  reports  a  similar  case.  Tn  both  eoeaine  was 
the  local  anavlhetie  used.  Death  was  attributed  in  each  ease  to  nerv- 
(Uis  explosion. 

Treatment. — (Jeneral  treatnu'nl.  mi  far  as  the  reirulation  of  the 
alinu'ntary  canal  and  the  tonin,u"  up  of  the  system  are  coneerni'd,  is 
always  advisable.  At  the  same  time  it  can  have  but  little  elTeet  in  eon- 
trolling  the  development  of  the  aih'iioid  disease.  Sj)rays  and  washes 
are  also  of  little  etiicaey  in  severe  eases,  and  tluMr  use  is  likewise  usu- 
ally resisted  by  the  little  sutl'erer.  When  the  hypertrophy  is  not  large, 
but  just  sullicient  to  produce  a  certain  amount  o\'  catarrhal  discharge, 
without  nnicli  stenosis,  this  may  be  nnnedied  by  a  slightly  stimulating 
or  astringent  spray,  of  which  tbe  following  is  a  good  exami)le.  Tt 
should  be  thrown  u[)  iiehind  the  jialate  once  or  twice  a  day  by  an 
atomizer: — 


k  il 

ler 

M'- 
il- 

|o- 

'11 

let 
lat 

t- 


1.     B   Acid,   laiiiiic 1 

Sod.  l)il)(ii ] 

Carbolic  ucid    

filyocriii    0 

.\()u;nn     lul  (ifl 

M. 

The  formula  on  llu'  following  page  is  another  excellent  spray  for 
ilie  same  ])urpose.  being  antiseptic  and  slightly  stimulating. 

One  ])art  of  this  alcoholic  solution  should  l)e  a(l<h'd  to  7  parts  of  an 


1.     B  Acid,  liiiuiic }jr.  XV. 

Sod.  liitxir K'"-  >^v. 

( 'arliolic    aiiil     iiiv. 

( Jlyccrin    3iss. 

Atpiain    ad  Jij. 

At. 


f 

! 

w^ 

M::i 


Hi 


212  DISKASKS    OF   Till-:    I'llA  I!  YN  X. 

nqiit'oiis  ^-])ci-((iit.  solution  of  Ijorie  acid,  and  used  with  an  atomizer 
to  the  iiojo  and  throat. 

].     U  Kiicalyi.tol     |25 

()1.  fiiUlltll.T i2 

AIciiUkiI     ,1 

'i'\\\  llKll      13 

Alcoiioi  ivct ;«>. 

When  Iroiii  our  caiisc  or  another  an  atoini/.cr  cannot  he  u.~cd,  the 
prt'jjaration  already  mentioned,  of  J-per-cent.  tJoliition  of  menthol  in 
al1)olene,  could  be  i^nulTed  uj)  the  nostril. 

Any  of  these  could  he  ust'd  two  or  three  time.-  a  ilay. 

When  the  adenoids  are  lai',i;'e.  I'cmoval  hy  sur;rical  operation  be- 
comes necessary.  'J'his  may  be  done  hy  the  use  id'  hot  or  cold  snares, 
galvanocautery-knii'e,  cutting  i'orcejis.  or  curettes.  It  is  impossible  to 
com])letely  destroy  the  sensibility  of  the  paits  by  application  of  a  local 
antvsthetic;  but  after  cliildhood  and  during'  adult  life  it  will  rarely 
be  necessary  to  administer  a  general  anaesthetic,  a  lo-  or  20-per-cent. 
solution  of  cocaine,  applied  by  means  of  a  cotton-hohlei',  being  all  tliat 
shoidd  be  reqnired. 

During  infancy  and  early  childhood  the  case  is  ditrerent;  and  my 
own  impression  is  that  an  amvsthetic  should  always  be  administered. 
If  the  adenoids  alone  require  to  be  rem<ived,  it  need  not  1)e  given  to 
the  extent  of  complete  ana?sthes;a;  but  the  o|)eration  can  be  performed 
so  much  more  easily,  rai)idly,  and  paiidessly  under  its  inlluenee  that 
the  advisability  of  its  use  can  scarcely  be  ([ueslioned.  The  choice  of 
the  anesthetic,  however,  is  an  exceedingly  important  matter,  the  safety 
of  the  patient  being  always  of  the  liighest  consideration.  Owing  to  the 
wide  i)reference  for  ether,  which  has  been  displayed  by  surgeons  for  so 
many  years  for  general  sui'gical  work,  many  are  tempted  to  use  it  for 
throat-\vork  also.  There  are  serious  objections  to  it,  however.  Xot 
01  ]y  is  it  believed  to  ])roduee  nmre  bronchial  congestion  and  ]iliaryn- 
geal  hypersecretion  than  chloroform,  and  also,  according  to  Linde- 
mann,  acnte  pidmonary  (cdema  during  or  after  the  narcosis;  but  what 
is  perhaps  equally  important  is  the  fact  tluU  the  vapor  of  ether  is  in- 

1.     R  Eucalyptol    viiv. 

01.  fraulllicr '"iij. 

]\I('iitli(il    ^i'.  iss. 

'J'liymel     jrr.  v. 

Alt'olinl  icct Sj. 


M 

.\A^()-J'11.\KV.\\.       ADK.Ndll).-. 


:.'K5 


lliiiiiiiial)lc,  iind   lliiit    it  wdiilil   lie  (liinncrmi.-  \o  ux'  ;i  ciiutciT   in  any 
J'orm  to  tlio  no?e  or  tliruat  whik'  lusing  (.'lliur  as  an  aiia'sthelif. 

l>roiiii(le  (if  ethyl  has  rct'ciitly  hcfii  I'fci'ivcil  with  i^rcat  l'a\(ir  lor 
thi'sc  ojicratidiis.  J>i.-liii|i  (■()n.-;i(li'r>  it  I'.ii'  ana'slhi'iic  jatr  e.rrellcncr  lor 
ihriiat-wdi'k  in  ihililrcn.  'J'hc  litlh'  patient  is  jihieed  in  a  silting-  ]in>t- 
ui'e  on  the  assi.stantV  lap.  an  onnee  iiihe  i<\'  hrmuiih'  ef  ethyl  is  einptieil 
into  the  air-ti.<;ht  inhaler  ami  atlininistered.  alhiwiiiLi'  no  air  to  enter. 
Ana'stlu'sia  is  indneed  in  ahoiit  (me  luinule  and  lasts  ahoiit  ilvo.  Ahmit 
one-halt'  the  hionude  is  taken  and  ennseionsness  (|niekly  relnrns. 
Mitrotis  oxide  aUn  dnrinu'  recent  years  has  ui'own  ra))idly  in  favor  as  a 
i-afe  ana'slhetii.     V^v  >hnrt  (ipei'atiuns  it   i-  adinirahlv  suited,  and  its 


1        ! 


rii'l 


■in  W 


Fig.  "().""  (il('il>niaiiii's   ioj    ami  J.i'iwciitirin's    i^i    iiiliiinid    t'lUi 


oU'eot  can  he  prolon^iicd  hy  eondiinini;'  it  with  nxyocn.     l.eiinnx  IW'nwne 
stronsrly  favors  its  use. 

The  chdiee  woidd  ^eein  \n  lir  hctwccn  iii'diiiide  of  ethyl  and 
iiiti'()ns  oxide.  The  cutnparat i\e  safety  of  the  two  it  i>  too  early  to 
positively  deei(h'.  One  advanta.u'e  of  hoth  of  them,  if  advantaji'o  it  is. 
lies  in  the  fact  that  they  ean  he  administered  in  a  sitting  posture.  As 
regards  siin])lieity  of  nianagenient.  however,  chloroform  would  seem 
to  have  the  advantage.  A  clean,  coarse  towel  is  all  the  instrument  re- 
(jTiired,  and  the  drug  >hoidd  always  he  given  j>cr  iinlhiliiii.  Often  a 
very  little  is  needed  and  in  a  I'vw  moments  the  operation  i-  all  over. 
A  few  deaths  liavc  been  recorded  froie  its  n-e  in  throat-work,  out  of 
the  tens  of  thousands  of  time.s  in  wliicii  it  has  Ihhmi  given;   hut  many 


!   ! 


■  ! 


'41 


*tv 


2U 


ItlSKASKS    OK     llli;    I'llAliVNN. 


Hi' 


'! 


of  tlioc  could  lie  iiiiccd  to  (iii'i'lrs-  iuliiiiiiist lilt ioi) :  iiiid  we  nrc  not 
sure  of  tlic  pci'Tc'ct  salVtv  ol'  aiiv  iiiia^tlictic  tliiit  luis  ever  lii'cii  UM'd. 

'i'hc  ^^iilviiiiociiiitcry  opcrntion  would  lie  iicrl'oniicd  as  already  do- 
ficribod  in  tlir  e-liaptcr  on  '■Naso-pliarynucal  Catarrli."  tlio  nioiitli-<:a,<r 
bcin;:'  inserted  and  the  palate  I'eli'aeted  liel'ore  the  eleelrode  is  passed 
into  the  naso-phai'vn\.  The  child  should  lie  recuiiilieiit.  with  the  head 
Ihrown  hack,  the  lace  heinji  liirned  towanl  tlu'  opi'raI<u'  and  with  snn- 
li^lit  playin<i'  upon  the  open  jiharvnx.  The  position  >lioul(l  he  the 
same  no  matter  what  instrnnu'iit  i.-  w^^'^l  in  the  ojieration.  parlieiilarly 
if  chlorid'orni  is  the  aiia'sthetic  elio>eii.  lu  ii-iiin'  the  caiiteiT  the  sense 
of  touch  should  he  a  sullicient  .u'uide  f(U'  the  iii>tiiiiiic!it. 

Snari's,  altliim<iii  u<('i\  hy  some  siir^'eoiis,  are  not  generally  con- 
sidered satisfactory  instruments  for  the  removal  of  adenoids.  When 
tliey  are  nsed,  whether  hot  or  cold,  the  snare  may  lie  ])assed  throiiirli 
tlie  Jiosti'il  (W  up  hehiiid  the  ])alate,  but  it  should  be  adju.-ted  to  the 
growth  by  the  forelinjicr  of  the  left  liand  ( l'"i,u's.  lit  to  '-u). 

Many  o])eralors  use  ])ost-|iliaiyn,<real  euttin,<:  forceps,  sucb  as  tliose 
of  liiiwenberg  or  (Jleitsmann  (l'"ij:\  ll!  a.  h).  taking-  the  adenoids  away 
piece  by  piece.  In  some  eases  the  whole  operation  is  completed  at  one 
time.  In  others  several  operations  are  required  before  the  adenoiils 
can  b(>  entirely  removed. 

Tlie  most  satisfactcu'y  instrunu'nt,  bowever.  and  tlio  one  most 
extensively  used  by  tlie  profession  at  the  present  time,  is  OottsteinV 
curette.  Of  this  there  are  various  sizes  and  several  modifications  since 
(lottstein  introduced  tlie  orijjfinal  design.  It  is  a  ring-instrument  witb 
tlio  cutting  edge  >-o  placed  that  in  the  downward  movement  it  will  lie 
in  contact  with  the  post-pbaryngeal  wall,  excising  completely  all  witbin 
its  grasp  (Kig.  77  n,  h,  r.  d).  Jn  using  it.  altbougb  the  moutb-gag  is 
rc(juired,  tlie  palate-retractor  is  not.  .After  amvstbesia  in  the  nprigbt 
posture — in  the  case  of  bromide  of  ethyl  or  nitrous  oxide  and  in  the 
recumbent  in  that  of  cbloroform — the  instrument  is  slip{)ed  u])  bebind 
tbo  jialate,  to  the  front  of  the  adenoid  growth.  It  is  then  jiressed 
against  tbe  vault,  and  brougbt  down  with  a  sharp  swei'p,  tlie  sliaft  of 
the  instrument  being  elevated  toward  the  nose  as  tbo  blade  descend^; 
along  tli(>  |)ost-pliaryngeal  wall,  tbe  central  ])art  of  tbo  adenoid  being 
swept  away.  It  may  be  at  once  reinserted,  first  for  one  lateral  jiortion 
and  tben  for  tbe  other.  'To  complete  tbe  operation  and  to  avoid  leav- 
ing any  loose  fragments  of  tissue,  it  is  ht'tter  to  pass  up  the  sterilized 
forefinger  of  one  band  afterward  and  scrape  tbe  surface  .clean  witb 
tbe  flnuer-nail. 


i    'i 


NASO-I'IIAUVNX.       ADKNOIDS. 


lo 


III  iildtT  piitit'iits  tlic  ciirottaj'O  can  l)c  doin'  in  the  (i|iri'atini,^-cliair 
iindor  cocaine  aiucsthc^ia,  and  witliout  the  use  oT  tlic  mmitli-.Lraj;. 

In  my  own  cxjx'ricnco,  the  hirj^c  majority  of  my  patients  have 
heen  eliihlren  l)et\vi'en  tlie  a^i,^'S  of  -1  and  Id  or  I".'  years,  and  I  liave 
niadi'  it  a  nde  to  operate  with  the  patient  lyinu  on  the  hack  with  the 
liead  h)W,  and  iii\arial)ly  to  liave  the  ana'sthetic  adniinistii'ed  hy  a 
ciualiiied  practitioner.  In  this  (dass  of  cases  I  always  optTate  dii;itally, 
iisinir  tile  nail  of  the  foreiiii^cr  of  either  1iand,  whichever  at  tho  time 


I     I 


i 


I'M 


(b) 


Fig.  77. — Adfiioid  curt'ttes:     ((/)    (iottstciii's;     {h}    Hoswoitii's,  rigid 
shank;    (c)  rayne's;     (*/)  Mungi'i's, 

is  tlie  mo.'it  convenient  to  use.  Tlie  soft  l)idpy  lymplioid  tissue  ran 
easily  be  stripjied  olf  at  a  8in<:;le  operation;  and  llu;  educated  di<,nt  can 
apply  itself  more  tlioroufjlily  and  ellieiently  to  tho  lateral  resfions,  be- 
tween the  Eustachian  tubes  and  the  sides  of  the  central  ])romontory, 
than  it  would  be  possible  to  do  at  one  sitting  with  the  curette  alone. 
When  the  tissue  is  too  dense  to  lie  removed  by  the  finger,  the  curette 
can  be  used  to  complete  tho  operation. 

The  objection  sometimes  made  to  this  nietliod  of  operating,  that 


! 


-nr, 


Dl.^KASKS    (If    rilK    I'llAliVNX. 


piii'tiilcs  of  adt'iioid  tis>iK'  aro  likely  td  drop  into  the  liiiynx.  is,  I  hc- 
litvc,  jjntimdlt'ss.  Tlic  rfcuiMljciit  jiosHiru  with  tlif  liciul  on  tlie  siinio 
level  with  the  liody,  iuid  with  it  turned  soniewlial  townrd  the  oporator 
and  tliidwii  hack  diiriiiL;'  the  o])eratioii.  and  the  nuiek  feveisal  to  the 
side  posilimi  to  iaeililate  the  luenmri'liaj^e  throiiL;li  the  na>al  [lassages 
into  the  howl,  will  m-iit ralix.e  this  tendency;  and  1  ha\e  imt  seen  a 
sin<;-le  instance  in  which  !  had  the  sliu'litcst  rea-nii  to  sus])cct  its  oc- 
cliri'enee. 

In  oldef  ydUtli-  and  adidts,  a-  .-aid  lietnt'e.  the  nperation  is  ])er- 
iornied  under  cocaine  anu'sthesia  and  in  the  oiieratinj^chair,  the  in- 
strmncnt  used  heing  one  form  or  other  (d'  (JottslcinV  curettes.  Jt  has 
usually  in  these  eases  reipiired  two  or  three  operations  to  secure  a  per- 
fectly satisfactory  residt.  My  use  (d'  post-nasal  forceps  lias  never  heen 
a  success,  although  I  have  tried  them  variously  modified  in  a  nuudicr 
of  instances. 

The  o])eration  is  always  nmre  or  less  paiid'id.  the  cocaine  never 
producing  complete  ana'sthesia  of  the  parts.  Still,  there  is  no  douht 
that  it  materially  niodilie-^  the  sensihility.  Cleansing  sprays  for  a  few 
days  after  the  (  |)i'iation  are  .idvisahle;  hut  they  should  not  he  com- 
menced until  thirty-six  or  forty-eight  hours  after  tlie  removal  of  the 
growth.  The  hydrocarlM^.i  oils  coidaiiung  V^  to  1  per  cent,  of  thymol 
or  menthol  are  among  the  hest  for  tlds  purpose. 

Sometimes,  though  rarely,  severe  Iwmorrliagc  will  follow  the  op- 
eratio.  for  the  removal  of  the  adenoids.  In  Jidy  of  the  present  year 
^lartin,  of  San  Francisco,  reported  three  cases  of  severe  hnGmorrhagc 
after  op(M'ation.  though  fiu'tunately  none  of  them  were  followed  hy 
death.  Schmiegelow,  one  year  ago,  gave  the  history  of  a  case  by  which 
the  o]>eration  was  followed  immediately  hy  a  gush  of  arterial  blood 
from  the  mouth  ami  nose;  and  in  a  few  minutes  the  boy  was  dead. 
Post-mortem  exanunation  proved  that  the  internal  carotid  artery  had 
been  puslu'd  out  of  ])osition  by  swollen  glands,  and  was  opened  by  the 
curette.  Several  years  earlier  Newcombc  reported  two  or  three  other 
cases,  including  oiu>  of  his  own,  in  which  death  occurred  from  general 
luvmorrhage  from  the  vault.  Fortunately  these  cases  arc  very  rare, 
though  not  infreiptently  severe  bleeding  will  occur  without  resrdting 
in  a  fatal  issue. 


rii.\rri:i:  x.wix. 


MYXOFll'.i;(i.M.\  <•!•   nil-;   NASd  l'IIAI!^■  NX. 


'  ■  i 


M vxoiMiiiiOMA.  or  |i()lv]iii>.  III'  till'  iiiiso-plianiix  is  of  compara- 
tively rare  occiirrciKi'.  Il  i-  !•■-<  inwnmatous  in  cliaractcr  than  wIrmi 
within  the  noso,  and  contain-;  innvc  lilirnii-  cnnncotivo  tis-uc.  llcnco 
it  must  1)0  considcrod  a  distimt  variety  nl'  ilie  disease.  The  surface  is 
di'cply  c'onirostod,  in  oontradi>iineiiiin  in  the  blue-gray  of  the  nasal 


■r 


.^i;'  4  '!« 


■^  ''■'*>'"  v"-  * 


I  I 


Fifj.   "S. —  Dr.  Crniifa  ciisr'  of  justiiMSiil   jmlyp-is. 

polypus,  whilo  its    freednm    truni    |ire--m'e   within   the   naso-pharynx 
enahles  it  to  attain  a  muoh  larper  size  (Fiir.  TS). 

Pathology. — 1'he  site  of  oriirin  of  polypus  influences  its  patho- 
loo'lcal  character.  The  onlinnry  iuueon<  ]iiilypus  ii,,.-  its  orisrin  usually 
along  the  summit  of  the  middle  uieatiis  hetween  th(>  middle  turbi- 
nated and  the  external  wall,  from  n  juire  mucous  membrane.  .As  the 
mucosa  descends  downward  over  the  Imdy  of  the  inferior  turbinated 
and  toward  the  post-rliinal  choana.  the  fibrous,  connective-tissue  ele- 
ments within  it  become  more  numerous.  7r(Mice,  the  polypus  spring- 
ing from  the  upper  portion   of  one  of  the   posterior  nares,  or  the 

(217) 


•»  1  V 

/vlO 


DISIiASIOS    OF    Tin:    I'MAUYNX. 


Ill 


jiinctidii  (if  llic  nose  aiul  I  lie  iiii.s(i-|iliiiryiix,  is  (•onipnpod  of  a  com- 
liiontion  of  Ixjtli  flciiiciils,  the  liliroii>  [ircpoiKlcratiil^'  over  the 
imu(jiis.  I. ike  iiiisiil  i)(»l_v|iiis,  tlic  histolojfical  (k'Hiiiiioii  is  tiiat  of 
loose  lli)roiiui,  tin;  fxlcnial  wall  hciiijr  of  denser  tcxliiri!  and  more 
lild'i'ally  sii|)i)lit'(l  with  hliKxI-vcssels.  'I'hcv  i\n  not  always  arise  from 
till'  eliiiaiia',  however.  Sictlioll'  re|)orts  a  ease  in  which  (he  tiiiimr  filled 
the  whole  <)[  the  post-nasal  >|Mee,  and  the  site  (d'  the  atlachnieiit  wad 
the  |ii)>terior  end  of  tiie  middle  Uirl)inated  hody.  Miiroseo|tieally 
it  \\a.>  an  adenoid,  eonneclivi'-tissne  <j:rowtli,  covered  with  stratilled 
and  ciliated  e|iilheliiini.  IJ.  A.  h'ceve,  of  'I'oronto,  also  icports  a 
jieenliar  ca-e  occnrriim  in  a  man  ai;cd  •JO,  The  growth  wa-  lonir  imd 
eveidy  thick  thronuhoiit,  visihle  in  the  pharynx  helow  the  soft  palate 
and  attached  to  the  summit  of  the  vault.  It  was  of  a  grayish-red 
eohn'.  'I'entat  ively  iodid.  |iot.  was  j^iven  in  lai'ne  doses  for  a  week. 
\\\  this  time  it  had  diminished  in  size;  so  that  the  drn^  was  (in- 
tinned  \ulhonl  opei'ation,  and  in  a  few  weeks  complete  aii.-or|ition  had 
taken    place. 

Etiology. — This  is  still,  in  a  measure,  an  unknown  (piantity.  Jt 
cannot  he  allirmed  positively  what  the  cause  may  he;  hut  as  the 
post-nasal  poly|)Us  heai's  some  relation  to  the  ordinary  myxoma  of  the 
nose,  not  infre(pieiitly  occuri'intr  in  the  same  individual,  the  causes 
may  he  identical.  They  are  said  to  oct'ur  more  fre(piently  in  females 
than  males,  and  hetwccn  the  iifteeiith  and  thirtieth  years.  They  are 
usually  siniile. 

Symptomatology. — The  ])rincipal  symptoms  are  those  caused  hy 
physical  intcrl'orcnce  with  res})iration,  voeali/iation,  and  dcfrlutition. 
As  it  lianfjs  down  from  one  posterior  naris,  it  occludes  the  passage 
on  that  side;  and,  the  enlarjicment  continuinif,  soon  lias  the  ell'ect, 
by  its  ])ressure,  of  closing  the  other.  Consequently  respiration,  of 
necessity,  becomes  oral,  Avhile  vocal  resonance  incident  to  a  normal 
condition  of  the  nasal  chambers  is  destroyed  by  the  ])resence  of  the 
growth.  Deglutition  is  interfered  with,  just  to  the  extent  that  the 
movements  of  the  palate  arc  linuted  by  the  pressure  of  the  polypus. 
Although  there  may  be  progressive  discomfort,  there  is  little  pain. 
As  the  growth  increases  in  size  it  may  project  below  the  palate  and 
be  visible  in  the  pharynx.  Like  other  nasal  ncoplasnis,  it  occasion- 
ally ])roduces  reflex  symptoms.  ]>osworth  reports  a  case  in  his  own 
practice  in  which  spasmodic  asthma  was  caused  by  the  pressure  of  a 
post-nasal  myxofibroma,  and  in  which  removal  was  followed  by  com- 
plete relief. 


NASU-I'llAUVW. 


MVXOKIIIUOMA. 


•.'!'.• 


Diagnosis.— lV)stcrif)r  rliino.scopic  cxaiiuiiatinii  slioiilil  iiiiikc  ilif 
round,  sinoctli,  ]tiiil\i>li  tiiiiiDr  visihlc  l''ri)in  inli'iinifl-i  it  \<  dis- 
tin^Miislic(l  liy  its  sito  of  ori;,Mii,  li^hliT  folor,  ami  |h,ii-,--Ii.i|m'(1  a[i- 
[icarance;  J'loiii  liliroiiia,  liy  more  regularity  of  oiilliiH'.  k'ss  rciliioss, 
and  no  tendency  to  liiPUiorrliage  on  lieing  toiiclicil  I'ost-tuiiiinal 
liyj)erlropliy  lia.s  a  nioro  (.'orriigaled  .surface,  dots  noi  project  far  into 
(lie  posl-rliinal  cavily  and  is  alway.s  ]iale  in  eolnr.  Animm  the  .-irik- 
ing  characteristics  (d'  po.st-na.sal  jiidypiis  are  the  facts  that  it  is  ea^jily 
niov.dde;  and  docs  not  produce  liaMiiorrhage,  erosion,  oi'  facial  de- 
formity; nor  does  it  pos,->ess  that  tendency  to  maliLMiniit  di\e|(i|)inent 
which  true  fibroma  is  supposed  to  do. 

Prognosis. — While  there  is  no  prohahility  of  the  luninr  leailiiii; 
to  a  fatal  issue,  its  renu)val  by  slougliinij;  or  al)Sorption  are  not  very 
])romising.  After  complete  rcmo\aI,  however,  hy  operative  measuri'S 
tlu'y  rarely  recur. 

Treatment.-  -f!vul,-ion  by  sironu;  serrated  fnreeps  thr(iui;ii  the 
mouth,  when  the  tumor  is  sullicienlly  lar>:e  to  be  ^M'a-jied  witiiiu  the 
naso-]iliarynx,  i>  one  of  tlic  best  nuMhods  n['  operation.  .\  l.")-per-cent. 
solution  of  cocaine  should  (irst  be  a])p!  i-d  freely  to  the  >;ro\\th  throiiudi 
the  nose.  Tliis  can  lie  done  hy  means  of  a  cotton-carrier.  Then,  l)y 
grasping  the  tumor  with  the  instrunu'id,  aided,  if  lu'cessary.  hy  the 
post-rhinal  mii'i'or,  it  can  be  drawn  down  to  obtain  fi'eedom  of  motion, 
and  twisted  olT  its  pedicle,  care  being  taken  not  to  x]:^^^  too  nnieli 
force  in  extraction. 

In  other  case?,  the  nasal  ]iassages  having  been  cleared  and  the 
ti.«sues  slirunken  Ijy  cocaine,  a  siuire  may  lie  passed  through  the  nasyl 
fossa  and  the  wirt'  adjusted  to  the  ])edicle  liy  a  linger  passed  within 
the  naso-pharynx.  'J'his  is  a  safe  and  in  many  cases  an  excellent 
method  of  extraction,  ])articularly  when  the  polypus  is  not  very  large, 
and  may  he  done  hy  eitlu'r  the  cold-wire  snare  or  galvanocautery-snare. 
Tlie  sjiring  of  the  former,  however,  renders  it  much  more  adjustable, 
and,  hence,  it  has  a  distinct  preference  over  the  pliahle  platinum  wire. 
When  the  cold  wire  is  used,  the  hase  of  the  growth  should  he  cauter- 
ized afterward,  and  the  ?ame  may  be  said  after  the  forceps  operation. 
In  using  the  cauiery-snarc  the  I'histachian  tube  shoidd  be  properly 
guarded. 

Some  writers  recommend,  in  certain  cases,  incision  into  the  soft 
palate,  to  increase  the  space  and  facilitate  removal.  With  modern 
appliances  for  intranasal  work,  this  should  rarely,  if  ever,  be  neces- 
sary for  removal  of  simple  myxofibroma,  however  large.     Under  co- 


ri 


1'  .■ 


14 


ni: 


220 


DISEASES    OF    THE    rnAUY>  >:. 


w 


{■aiiio  the  .i^rowlli  ciiii  be  taken  away  IlirniiLrli  tlie  nasn-ii'iarviix  with- 
out resorting  to  eutting  operation:?  iiild  the  normal  ti.^sue.  Later  ex- 
porienee  lias  proved  tliat  in  many  eases  the  eohl-wire  snare  passed  up 
beliind  the  palate  is  the  best  method  (if  removal. 

I  have  seen  three  eases.  The  (irst  was  a  child  aiied  •")  vi  ais.  The 
pinkish,  soft  growth  was  visible  lianging  down  behind  I  he  palate. 
Under  chloroform  I  attempted  to  remove  it  with  post-ii;)sal  i'orcc^ps; 
but  the  atlaehment  would  slip  from  the  grasp  ol'  the  instrmni'nt. 
raili:.g  this,  I  serajied  it  from  the  child's  left  posterior  ehoana  with 
the  nail  of  the  riuht  I'oretinger.  This  oeeurred  four  years  ai^^o  and 
there  has  been  no  return. 

The  secnnil  w;!s  in  a  man  jiasl  middle  life.  'I"he  ginwth  had 
formed  from  a  large  sessile  base,  an«l  was  attached  to  the  upper  part 
and  on  both  sides  of  the  posterior  end  of  the  septum.  It  partly  filled 
both  posterior  nasal  fossa%  and  lay  up(jii  the  upper  surface  of  the  soft 
palate.  I  found  it  impossi1)le  to  pass  the  snare  around  it.  'I'ho 
surface  was  suiooth  and  glistening,  and  of  a  grayish-])ink  eoloi'.  With 
the  posterior  rhinoscope  slipped  behind  tlu;  growth,  the  base  eoidd  ])e 
seen  attached  to  the  central  part  of  both  ch()ana\  With  posterior 
nasal  force])s  part  of  it  was  removed.  The  galvanocautery-knife  was 
then  passed  through  the  anterior  nares,  first  on  one  side  and  then 
on  the  other,  an  incision  being  made  in  i  ;ieh  ease  through  the  at- 
tachment  close  to  the  septum.  Several  days  later,  the  attachment 
having  loosened,  the  l)ulk  of  the  growth  was  removed  by  the  forceps 
from  behind.  The  extended  base  was  then  singed  by  a  curved  elec- 
trode })a.ssed  tlirough  the  nares.  Spray-treatment  for  cleansing  pur- 
poses was  subse(iuently  used.  Three  yea/s  later,  at  the  ago  of  60, 
there  wa^  no  return. 

1\.  A.  JJeeve,  of  Toronto,  has  reported  another  case  of  myxo- 
fd)roma  of  the  naso-pharynx.  Unlike  the  one  already  referred  to,  this 
one  had  reached  an  imnuMisc  size.  It  occurred  in  a  woman  iiLfed 
49.  On  examining  tlic  nose  anteriorly  something  resembling  myx- 
omatous tissue  seemed  to  fill  the  lower  portion  of  both  nasal  fos.^ac. 
Q^he  masses,  however,  were  not  attached  to  the  turl)inateds  as  they 
usually  are  in  ordinary  cases  of  nasal  polypi.  On  examining  the 
throat  the  growth  was  found  to  fdl  the  whole  naso-pliarynx.  Tn 
order  to  remove  it,  a  vidsellum-forceps  was  bent  to  a  suitable  angle 
and  the  tec  th  blunted.  The  instrument  was  carefully  passed  up  be- 
hind the  palate  and  the  body  of  the  growh  seized  near  its  attach- 
ment to  one  of  the  posterior  ehoana}.     With  comparatively  slight 


I 


liev 


the 
In 

i)c- 

ich- 


XAso-ru  A  i;  vn  x.     m  yxofibuo.m  a  . 


/»  V  1 


1^ 


ht 


Iriulidii  the  wliolo  innss  was  removed  in  one  piece  '''he  projocting 
teiUaclcs  lying  in  the  inferior  nienti  were  hut  overL:.  »\ths  of  a  huge 
polypu-:,  and  slipped  backward  and  out  withoi'*"  severing  their  con- 
neclion.  Oil  cxaiiiiiiatinii  the  altachiucnl  pnuMl  I  ■  he  by  a  eoiiipara- 
tively  small  pe(li(  h'.  which  was  scvrrcd  hy  the  trai-tion  of  the  \iilsi'l- 
hnn.    As  a  I'esiih,  the  jiatient  received  eiilire  and  permanent  relief. 

Since  writing  tlie  ahove  the  following  ca-c>  have  heen  recorded: — 

Weil  (Wrincr  ineilirinisrhc  ]Vorliensclirifl,  Jaiiiiarv.  lS!)i))  reports 
one  case.  It  wa-  atlachc(|  all  along  the  posterior  v{\'j^^'  of  the  vomer. 
Two  hemispherical  ])rocesses  filled  the  naso-pliarynx  and  caused  com- 
plete nasal  ohstniclion.  One  largi'  hraiich  of  the  polypus  lilleil  the 
right  nasal  cavity  as  far  as  the  anterior  naris,  while  a  pear-shaped  por- 
tion, whose  lower  extremity  could  only  he  seen  l>y  strongly  depressing 
the  tongue,  covered  the  whole  post-pharyiigi  al  wall.  Weil  removed 
it  throuiih  the  po~t-pharynx  in  one  jiiece.  lis  weight  was  forty-live 
gramiiKs. 

]\rax  Thorner  (Lnnjiiijoafopr,  .\[)i'il.  iSliii)  reports  another,  which 
wa-^  even  larger.  Ifearing  was  much  dimini-hed.  there  was  complete 
na^al  stenosis,  and  the  voice  had  the  characteristic  nasal  twang.  The 
left  nasal  fossa  was  free,  hut  the  right  one,  posteriorly,  was  filled  with 
the  mass.  The  attachment  was  at  the  posterior  portion  of  the  right 
nasal  fossa.  It  was  removed  rn  itimi^o  hy  means  of  a  cold-wire  snare 
passed  np  l)chind  the  palate  and  around  the  growth.  It  was  composed 
of  many  large  and  small  nodules,  some  of  them  of  the  size  of  a  small 
hen's  v'^i:.  'I'he  jiedicle  was  slendi'r.  not  larger  than  a  lead-pencil. 
'I'he  wt'ight  was  fifty  grammes.    The  ]iatient  was  a  man  aged  30  years. 

The  author  might  likewise  ri'fer  lo  one  which  he  removed  from 
the  naso-pharynx  of  a  woman  aged  lit.  on  .\pril  "M,  1S!I!).  'I'he  phy- 
sician who  hronght  this  case  for  trcalment  had  already  removed  a 
jiolypus  fr(Uii  the  left  nostril.  The  jirnlniliiljly,  however,  is  that  this 
was  only  a  ju'ojection  forward  of  the  oi'iginal  growth  into  the  naris 
from  the  naso-pharynx.  On  th(>  left  side  there  was  complete  stenosis. 
I'ost-nasal  examination  revealed  a  li.i^e  lohulate(l.  nrm.  and  pinkish 
tumor,  filling  the  jiost-nasal  pharynx.  .\  cold  snare  was  passed  u|) 
behind  the  soft  ])alate.  and  was  ad.iiisted  over  the  growth  by  the  index 
(Inger  of  the  left  hand.  The  wliole  was  removed  in  one  mass.  Al- 
though much  smaller  than  the  two  already  recorde(l,  its  weight  was 
sixteen  gramme-^. 

The  author  would  also  like  to  make  one  remark,  which  so  far  ho 
has  not  observed  in  reading  np  the  literature  upon  this  subject,  and 


i;l 


■ 


II 


ilh 


ii 


222 


DISEASES    OF    THE    PHARYNX. 


lU 


that  is:  wlionevor  a  true  fibroma  (Kdematosa,  or  naso-pliaryiigoal 
polypus,  is  successfully  removed,  it  is  iisually  taken  away  in  a  single 
])iece.  It  is  dillieult  enough,  and  requires  care  and  patience  to  adjust 
the  snare  well  up  around  the  body  of  the  tumor;  but  it  is  next  to 
ini])(issible  to  press  the  wire  closely  npon  all  sides  of  the  mass  so  as 
to  gras])  oidy  the  pedicle.  8li!I,  when  the  snare  is  tiglitened,  it  docs 
not  sever  a  piece,  l)ut  reuKives  the  whole.  The  reason  is  oi)vious  on 
examining  the  structure  of  the  polypus.  The  body  has  often  been 
years  in  growing,  and  is  dense  and  fibrous  and  innssivc  in  character, 
while  the  pedicle  is  formed  largely  of  blood-vessels  and  mucous  mem- 
brane, and  contains  comparatively  little  fdjrous  tissue;  and  henco 
yields  more  readily  to  the  traction  ]ihu'ed  upon  it  than  does  tlie  body 
of  the  tumor. 


I 


■al 

to 
as 
ocs 
on 
icn 
[er, 
■ni- 
ne 0 
ixlv 


1 


CHAPTlvU  XL. 
FIBROMA  OF  THK  NASOl'lIAHVNX. 

This  disease  clifl'ers  materially  from  the  one  rccnr<lc(l  in  the  pre- 
vious chapter,  hein^  composed  almost  entirely  of  (ihrous  tissue  and 
having  its  origin,  many  authorities  say,  from  the  base  of  the  occipital 
bone,  near  its  junction  with  the  sphenoid,  insiead  of  in  the  choanal 
region.  It  dilVers,  too,  in  its  slow,  steady,  and  relentless  growth, 
crowding  its  way  onward  irrespective  of  the  natnic  of  the  invaded 
tissue,  and  ])roducing  absorption  of  bono  as  well  as  (ithci'  tissues  if 
its  way  is  impeded.  With  regard  to  origin,  however,  ('apart  says  that 
in  history  of  fifty  eases  he  has  usually  found  the  tunu)r  to  arise  from 
the  internal  surface  and  base  of  the  pterygoid  apophy>ii.«,  and  always 
on  the  right  side. 

Pathology. — 'I'liese  tumors  always  oeeur  singly.  The  attaelnnent 
is  by  a  broad  surface  or  pedicle,  and  sometimes  the  surfaee-attach- 
nient  expands  with  the  growth  of  the  neoplasm.  In  color  they  are 
a  dark  red,  though  sometimes  of  a  brighter  or  ]iinkish  hue.  They 
have  a  hard  or  dense  texture,  and  at  first  ,i  I'ounded  form  and  smooth 
surface.  'J'he  latter  changes,  and  irret,niiarily  oeeuis  as  the  disease 
advances.  'J'hey  ar(^  formed  of  ise-grained.  white,  fibrous  ti-sue 
])lentifully  supplied  with  blood-vi  '-.  Scattered  through  the  lihrcs. 
which  often  interlace,  are  found  the  arteries  and  veins,  and  around 
these  arc  numbers  of  fusiform  cells.  The  >«  ho1(>  tumor  is  inclosed 
in  a  capsule  derived  from  the  mucous  mendnane.  In  addition  to  the 
vessels  that  permeate  the  growth,  there  are  nunieroiis  i»lood-spaf'e.<j, 
some  of  them  lying  directly  lielow  the  outside  coating  of  the  fibrous 
neoplasm. 

Etiology. — In  lUsbop's  ])ithy  words:  '"'i'lieir  cause  remains  in 
obscurity."  This  is  true  in  regard  In  many  diseases.  Xotwitlistand- 
ing  the  rapid  progress  medical  seiene(>  has  made  during  recent  years, 
we  arc  still,  in  refereiu'e  try  etiology,  gro))ing  in  the  dari-.  .,nd  how 
far  bacteriological  research  will,  in  the  near  future,  enable  us  to  jilace 
this  division  of  the  science  ujion  a  sound  basis  yet  remains  to  be  seen. 
The  majority  of  cases  oeeur  in  males,  and  during  the  years  of  early 
maturity,  the  disease  rarely  enmnuMieing  after  the  age  of  twenty-five 

mil) 


!  '! 


$ 


S.  '  ' 


224: 


DISKASES   OF   THE    I'HAKYKX. 


il 


years.  Tlio  surface  blood-vessels  of  tlie  growth  are  larger  than  those 
of  the  interidr;  hence  tlie  tendency  to  ha;niorrliage  from  mere  sur- 
facc-ahrasinii. 

Symptomatology. — 'Die  must  prominent  symptom,  apart  from 
those  of  nasal  stenosis,  wjiich  have  already  been  more  than  once  de- 
scribed, is  that  of  fre<jnently-recurring  ejtista.xis  arising  from  the 
bursting  of  some  of  the  numerous  venous  sjiaces  on  the  surface.  This 
is  possibly  caused  by  friction  with  the  soft  palate.  Tlie  amount  of 
bleeding  dilVers  from  a  few  drops  to  copious  and  even  dangerous 
Invmorrhago.  As  the  growtli  increases  in  size  it  will  i)ress  the  palate 
downward,  often  causing  serious  dcrniniity.  In  the  same  May  it  may 
extend  anterio"ly  into  the  nasal  fossa'.  dis})lacing  the  nasal  bones  and 
producing  deformity  even  of  the  face  itself.  There  is  usually  con- 
siderahh?  muco-puruk'iit  or  niucd-sanguincous  discliarge.  'i'he  intcr- 
ferciu'c  with  nasal  respiration  and  the  pressure  of  the  palate  down- 
ward will  alfect  deglutition  and  induce  pharyngeal  and  laryngeal  com- 
plications. The  stenosis  priMluced  by  naso-pliaryngcal  fibroma,  al- 
though unilateral  at  lirst,  soon  becomes  bilateral,  gradually  fUling  u]) 
tiic  whole  post-nasal  cavity. 

Diagnosis. — I'ost-rliinal  examination  sliould  distingui>h  it  from 
any  other  disca>e.  evtii  at  an  early  dale.  Xaso-]iharyngeal  fil)roma  is 
less  regular  in  nuiline  tlian  myxolibroma  and  of  a  redder  hue.  Tlie 
former  is  hard,  the  latter  soft:  it  will  also  bleed  on  touching,  ^hile 
the  naso-jiliaryngeal  polyjuis  will  udt.  lieneath  the  reddish-])ink  sur- 
face of  tlie  filiroma  the  white  llbrous  tissue  may  sometimes  be  seen. 
While  the  tumor  is  hard  to  toiuli,  it  can  easily  be  distinguished  from 
the  still-liarder  texture  of  osteoma.  One  other  characteristic  wliich 
distinguishes  it  from  all  other  neoplasms,  except  those  of  a  malignant 
character,  is  the  teiideuey  to  oft-re])eated  lumnorrhage. 

The  ])()ints  of  dilference  between  fibroma  and  the  malignant  dis- 
eases, sarcoma  and  carcinoma,  will  be  dwelt  upon  when  dealing  with 
these  subjects. 

Prognosis. — If  unnmovMl  by  .ipcrativc  measures  the  tendency 
is  toward  a  fatal  result,  ])artly  owing  to  the  repeated  lucmorrhages 
which  so  frequently  occur.  These  growths,  however,  rarely  develoj) 
after  puberty;  and,  that  age  lieing  reached  without  a  fatal  issue, 
development  may  sometimes  be  arrested  and  giadnal  shrinkage  of 
the  tumor  ens\ie.  Several  cases  have  been  recorded  in  which  this  has 
occunvd.  Still,  it  is  not  wise  to  postpone  treatment  with  the  hope 
of  such  an  issue,  for.  if  unarrested,  the  surromiding  structures,  no 


'1 


[lo]) 


lias 

lope 

no 


NASO-rilAUYXX.       I'lHHOMA.  •.'•-.'•) 

matter  liow  vital  their  cliaractcr,  are  likely  to  be   invadud   l)y  tlie 
disease. 

Treatment. — These  growtlis  should  invariably  be  roniovod,  if 
there  is  any  ju'ospect  of  tliis  being  aeconi])lished  without  ineurring 
risk  of  life.  When  at  all  possiblo,  too,  tlie  operation  should  be  per- 
formed per  lias  natiiralcs.  There  are  few  instances  requiring  the 
radical  method,  projjosed  by  some  writers,  of  removing  the  upper 
maxilla.  If  necessary,  it  woidd  be  better  to  divide  the  soft  palate  in 
order  to  reach  the  base  of  the  growth.  Tlie  ])a]ale  is  not  alTeeted 
except  by  pressure,  having  no  allachnu'iit  to  the  tumur  itself. 

Operation  by  galvanoeaulery-eeraseur  is  considered  one  of  the 
best  methods  now  adapted,  as  Ijy  tin;  slow  action  of  the  cautery 
haemorrhage  may  be  prevented.  After  ))assing  the  snare  through  the 
nasal  fossa  the  platinum  wire  is  adjusted  to  the  l)ase  of  the  growth  in 
the  vault  by  the  finger.  Then  the  wire  is  drawn  so  as  to  grasp  the 
tissue,  and  the  electric  current  turned  on  at  a  red  heat,  and  slowly 
tightened  until  the  growth  is  excised.  Tliis  operation  is  easy  to 
describe,  but  difficult  to  accompli.sh,  especially  with  the  instruments 
that  are  now  in  use.  The  platinum  wire,  wbcn  drawn  tightly,  will 
often  break,  particularly  when  at  a  dull-red  lieat,  and  the  y)art  to 
which  it  has  to  be  adjusted  is  difficult  to  manipulate  with  so  soft  a 
wire. 

Still,  14  cases  arc  reported  liv  Linenln  as  treated  in  tliis  way. 
Of  these.  11  were  cured,  wliile  in  the  dIIkt  :>  I'eeiii'rence  took  place; 
whereas  in  iJS  operations  in  wliieli  the  superior  maxilla  was  resected 
10  were  cured,  8  died  from  the  operation,  11  recurred,  and  9  were 
incomplete.  In  7  operated  on  through  the  jialate  2  recovered.  2  re- 
curred, 1  died,  and  2  were  incomplete. 

In  some  cases,  where  the  galvano-eeraseiir  i^  unavailable  or  does 
the  work  incompletely,  the  galvanocautery-knife  may  do  better  serv- 
ice. It  will  require  great  care  in  manipulation  to  jirevent  lui'mor- 
rhage. 

Operations  by  cutting  forceps  and  the  curettes  in  the  early  stages 
have  been  tried,  but  the  same  care  against  excessive  bleeding  requires 
to  be  taken. 

Bosworth  ])refers  the  cold  steel-wire  snare,  applied  in  the  same 
way,  the  instrument  being  a  stronger  one  than  those  ordinarily  in 
use  and  made  of  the  Jarvis  type,  with  a  bar  to  tighten  the  screw  in- 
stead of  a  wheel. 

Capart  and  Ingals  favor  electrolysis  in  the  ti'eatnient  of  this  dis- 


^nt 


!i 


iJxJG 


DISEASES   OF   THE   PHARYNX. 


i;! 


eai-c.  It  has  the  advantage  over  all  others  of  being  unattended  by 
iiffiinorrhage,  and  when  the  parts  are  freely  cocainized  it  is  not  very 
painful.  It  may  be  j)racticcd  cither  by  the  bipolar  or  monopolar 
method.  In  ihe  former  the  po.sitive  and  negative  nt'cdlcs,  properly 
protected,  are  pa.ssed  side  by  side  directly  into  ihe  tumor  at  the  dis- 
tance of  half  a  centimetre  from  each  other.  Tlii.>;  can  l)c  done  eitlu^r 
through  the  cocainized  na^^al  fo<sa  or  by  curved  needles  into  the 
growth  from  bcliind  the  palate.  Tlie  current  should  be  between  15 
and  "2')  milliani]:iere.s  and  l!ic  time  at  cacli  sitting  ten  to  twenty  min- 
ule.<.  By  the  monopolar  method,  the  right  pole  might  be  a  large  flat 
electrode  applied  to  tlie  cervical  s|)iiu',  and  the  left  ]iolc  a  needle  in- 
serted into  the  tissue  a.s  before.  'J'hc  number  of  trc;itmcnts  required 
woukl  vary  materially,  sonu'  re(]uiriiig  a  large  number  and  others 
comparatively  few.  WJien  the  electrolysis  is  not  destructive  of  the 
tumor,  it  may  have  a  contracting  ell'ect  upon  the  calibre  of  the  blood- 
vessels, thus  limiting  the  arterial  supply  and  rendering  subsequent 
radical  operation  less  dangerous.  The  frequency  of  treatment  would 
be  every  two  or  three  days. 

Whatever  jtlan  is  followed,  the  parts  can  be  kept  as  aseptic  as 
possible  by  the  use  of  cleansing,  antiseptic  sprays. 


^1 


\U  6 


ClIAPTFJl  XLi. 

MALIGNANT  DISEASES  OF  THE  XASOPllARYXX: 
SARCOMA  AND  (  AIMIXOMA. 

Sarcoma. 

ArALlGX.WT  (lisc'ii^os  of  tlii>  n\ui(ui  nrc  \ti\v  rare,  luil  of  ihe  two 
— siircoina  ami  cai'C'iiioiiia — sarcoma  is  iiiiii-li  more  i'r(M|iirtit. 

Pathology.— Tlie  oriji;iu  of  sarcoma  of  the  nasii-pharvnx,  like 
fibroma,  is  usually  from  the  iieiLrliborliood  of  the  union  of  the  basilar 
process  of  the  occipital  bone  with  the  sphenoid.  The  tiuiior  is  more 
sessile  in  its  attachment  than  iil)roma.  It  starts  in  the  deeper  layers 
of  the  mucosa,  and,  while  the  liase  is  expanding,  the  growth  dc\elops 
downward,  with  a  lobular  surface,  rapidly  lilling  the  post-jiharynx, 
and  sometimes  extending  forward  through  the  post-nares  into  the 
nasal  cavitic«.  Histologically  it  jiresents  the  usual  characteristic  feat- 
ures of  sarcoma,  with  large  and  small  round  cells  and  dense  fdjrous 
connective  tissue.  The  growths  are  of  softer  texture  than  fibroma, 
and,  hence,  are  less  likely  to  displace  the  dense  osseous  tissues. 

Etiology. — The  bacillus  of  sarcoma  has  so  far  not  been  dis- 
covered, but  it  is  more  than  probable  that  it  is,  in  all  cases,  of  bacil- 
lary  origin.  It  usually  occurs  in  early  life,  in  this  way  differing  from 
the  rarer  diseas'\  carcinoma.  Still,  it  does  occur  occasionally  even 
in  extreme  age.     It  is  more  fretiuent  iit  males  than  I'etnales. 

Symptomatology. — In  tlie  early  stages  the  symptoms  do  not  dilTer 
materially  from  those  of  the  diseases  already  described  which  impede 
nasal  breathing.  There  is,  however,  somewliat  early  in  its  history  a 
characteristic  discharge  of  od'ensive  malodorous  sero-pus.  IIa;mor- 
rhage  sometimes  occurs,  though  less  frcdiirntly  and  less  severely  than 
in  the  milder  disease,  filiroma.  The  general  health  likewise^  suffers. 
A\'hen  the  sarconui  grows  large,  it  interferes  with  the  normal  condi- 
tion of  the  adjacent  organs,  pressure  on  the  Kustachian  tulx's  pro- 
ducing deafness  to  a  more  or  less  degree,  and  invasion  of  the  pharynx 
inducing  ditRcult  deglutition  and  vocalization.  Shooting  pains  to  the 
cars  sometimes  occur. 

Diagnosis. — Sarcoma  of  the  naso-pharynx  is  to  be  distinguished 
from  carcinoma,  fil)roma,  tuberculosis,  and  tertiary  syphilis.  Its  soft, 
grayish,  ])ultaceous  appearance  should  distinguish  it  from  the  harder 

(2ar) 


)i'iS 


niSKASES    OF    TIIK    rirAUVNX. 


m 


Pi 


I  i" 


s  i. 

11: 

1  ' 


niid  pinker  liliroiiiii.  From  carcinoma,  llie  age  of  the  ])atient  sliould 
lu'lp  in  the  (liii;:no»i.s.  Tlic  cxcci'ding  rarity  of  carcinoma,  also,  to- 
gether witli  its  more  mai'ked  cachexia  and  greater  tench'ney  to  be 
associated  witii  ghmdular  enlargemenl,  sliouhl  lielp  in  tliis  matter. 
As  to  tul)ereulosis  and  sypliilis,  the  general  constitutional  symptoms 
and  perM)nal  history  should  nialerially  aiti  in  forming  a  correct  con- 
clusion. 

Prognosis. — The  younger  tlu'  patient,  the  more  ra])id  the  ])rogrcss 
of  the  dist'ase.  This  is  never  toward  resolution,  but  always  toward  a 
fatal  issue.  Small-celled  sarcoma  is  said  to  be  mon;  rapidly  fatal  tlian 
the  large  round-celled  or  the  spindle-celled  varieties.  Fibrosarcoma, 
wliicii  is  merely  a  combination  of  the  fibrous  witii  the  malignant  dis- 
ea.«e,  is  slower  in  development,  although  more  likely  to  be  attended 
during  its  course  by  attacks  of  severe  luemorrhagc.  l^ven  after  suc- 
cessful removal  by  operations,  in  the  majority  of  instances,  recurrence 
takes  ]»lace,  a  very  small  ]ierccntagc  of  recoveries  having  been 
reeoi'ded,  wliile  a  large  number  of  patients  have  died  on  the  ()])erating- 
table. 

Treatment. — As  a  rule,  jialliative  nu-asures,  with  mild  cleansing 
wa.-hes  to  tlie  parts  alfected,  are  the  only  justifiable  means  of  treat- 
ment. The  general  system  should  be  supported  by  tonics  and  good 
digestilde  food,  wliile  hygienic  conditions  should  he  carefully  at- 
tended to. 

The  results  of  operative  treatment  are  usually  very  unfavor- 
able. The  old  method  of  sjilitting  the  palate  and  dissecting  out  the 
grDwth;  and  tiie  larger  one,  of  icnioving  a  porti(Ui  of  tlie  upper 
maxilla,  to  get  at  the  pedicle  of  the  disease,  have  hi'en  attended  almost 
uniformly  by  a  fatal  result.  IJryson  Delavi!n.  however,  reports  a  case 
wliich  sei'ins  to  be  an  exception.  After  the  sarcoma  had  developed, 
until  it  partly  idled  the  naso-})harynx,  and  almost  entirely  the  left 
nasal  cavity,  electrolysis  was  resorted  to  and  carried  on  for  a  year. 
I'nder  its  ufic,  haemorrhage  ceased,  the  growth  shiank.  and  health 
improved.  J>y  that  time  it  lost  its  ellicacy,  and  operation  was  ])er- 
fornu'd,  removing  the  growth  as  thoroughly  as  ]jossiblc.  l^ecurrenee 
was  soon  very  marked,  and  o])eration  was  again  performed.  This 
time  the  njipcr  jiart  of  the  left  superior  maxilla  was  removed,  and 
the  growth  found  to  be  attaehed  to  the  sphenoid  sinus.  It  was  ex- 
cised thoroughly.  An  o]iening  was  left  in  the  hard  jialate  by  which 
the  site  could  be  watched.  It  recurred  slightly  several  times  and  was 
each  time  burned  awav  with  galvanoeauterv.     On  recording  this  case 


NASO-1'IIAUYNX.      CAHCINOMA. 


four  months  had  eUipsod  without  any  rutuni,  and  the  youtli,  aged 
17,  was  well. 

liosworth  reports  a  case  cured  in  a  gentleman  aged  42.  This  was 
done  by  repeated  snaring  nf  small  pDrtioiis  of  the  growth,  carried  on 
daily  for  several  weeks,  and  follnwed  hy  a  series  of  galvanoeautery 
operations,  conducted  in  like  manner.  After  a  time  the  sarniiiia  was 
entirely  removed,  and  seven  years  later  there  had  been  no  return. 

Logan,  in  ISIM,  rejiorted  a  somewhat  similar  case.  In  this  a  num- 
ber of  smire  operations  had  been  performed,  but  all  were  followed  liy 
rapid  recurrence  of  the  disease.  Finally  the  case  fell  into  his  Jiands. 
lie  tied  the  jtalate  forward  an<l  found  the  growth  attached  to  the  riH)f 
of  the  naso-pharynx.  Jle  divided  the  growth  into  several  sections 
and  removed  each  section  by  a  galvanoeautery  operation.  Si.x  years 
later  the  sarconui  had  not  returned  and  the  man  was  in  perfi'ct  health. 

In  all  these  cases  microscopical  examinations  proved  the  correct- 
ness of  the  diagnosis. 

In  Bosworth's  case  as  well  as  Logan's  it  will  be  noticed  that  the 
linal  successful  work  was  done  by  the  galvanoeautery:  a  clear  indica- 
tion of  the  value  of  this  instrument  in  dealing  with  malignant  disease. 

If  the  tumor  is  taken  early,  and  can  l)e  removed  piece  by  })iece 
by  means  of  the  galvanocauteiy,  which  can  be  so  controlled  as  to 
occasion  but  little  luBmorrhage,  we  are  certainly  justified  in  making 
the  attempt.  By  this  means  we  also  save  the  jiossibility  of  autoinfec- 
tion,  which  might  occur  througli  knife  operation  upon  unafl'ceted 
tissues. 


1 


Cakcin'oma. 

The  literature  u]ion  this  subject  is  confined  to  the  liistory  of  a 
few  reported  cases.  The  disease  ri'sembles  sarc(nna  in  many  ways,  and 
is  so  invariably  fatal  that  little  need  be  said  of  it  here,  liare  as  is 
sarcoma,  carcinoma,  the  more  malignant  of  the  two,  is  still  more  rare. 
A  few  important  ])oints  are  woitby  of  notii-e.  however:  It  is  a  ilis- 
ease  that  almost  always  occurs  late  in  life.  I'nlike  sarcoma,  it  is  also 
attended  by  profuse  glandular  enlargcnu'ut  and  a  general  ap])oaranco 
of  malignant  cachexia.  ]\Iicrosco])ically  the  presence  of  epithelial 
cells  distinguish  it  from  sarcoma. 

The  prognosis  is  nniforndy  unfavorable.  Operative  treatment  is 
useless,  mild  cleansing  and  supporting  measures  being  all  that  can  be 
of  any  avail.  Opiates  internally  and  the  local  ap])lication  of  cocaine 
may,  in  the  latter  stages,  afford  a  certain  measure  of  relief. 


'  I    ti 


2;{() 


DISEASES    OF   THE    I'lIARYNX. 


Chondroma  of  the  Naso-piiarynx. 

This  non-malignant  disease  is  so  exceedingly  rare  that  only  mere 
mention  of  it  will  be  necessary.  The  symptoms  are  those  of  ordinary 
stenosis.  There  may  alno  lie  occasional  attacks  of  headache  and  also 
of  syncope.  Post-nasal  examination  reveals  the  presence  of  a  hard, 
dense,  whitish  growth.  Microscopical  examination  of  segments  show 
tlio  cartilaginous  character  of  the  neoplasm.  There  is  no  tendency 
to  malignancy.  Surgical  operation  will  he  reiiuired  for  removal. 
There  should  he  no  return  of  tlie  disease. 


lM)lii:i(iN'     r.ODIKS. 

Somciimcs,  lliougli  rarely,  foreign  bodies  become  lodged  in  the 
naso-jiliarynx.  Although  they  ju'oduce  symptoms,  they  may  remain 
for  years  before  they  are  discovered.  The  two  following  are  interesting 
cases  and  worthy  of  note: — 

\l.  I'atterson  {Jatirnal  of  Litriititjnior/!/,  'May,  189!))  reports  a  for- 
eign hody  impacted  in  the  naso-pharynx  for  four  years.  This  was  a 
mt'fal  regulator  of  an  infant's  feeding-bottle.  Tt  was  removed  from  a 
child,  aged  0  years,  suffering  from  otorrhtfa  of  the  left  side,  with  foetid 
discharge  from  left  nostril.  There  was  also  complete  nasal  stenosis, 
and  something  could  be  distinguished  in  the  ])ost-pharynx  on  looking 
through  the  left  nasal  passage.  Tnder  anivsthesia  a  hard  mass  was 
discovei'ed  and  removed  from  the  naso-pharynx,  and  was  found  to  be 
the  body  mentioned,  thickly  coated  with  phosphates. 

The  history  obtained  was  that,  when  the  child  was  fifteen  months 
old,  while  playing  with  a  regulator  it  suddenly  showed  difTicnlty  of 
breathing.  This  was  relieved  by  suspending  the  head  downward. 
From  that  time  nasal  breathing  became  obstructed,  and  the  child's 
health  suffered.  At  various  times  subsequently  bougies  had  been 
passed  into  the  o'so])hagu.-'  by  medical  men,  to  prove  to  the  parents 
that  the  foreign  body  was  not  still  in  the  throat. 

TI.  S.  liirkett  {Monrrcal  Mcdiral  Journal,  June.  1S99)  reports  a 
foreign  liody  in  the  naso-pharynx  for  eighteen  years  and  gives  the  his- 
tory of  this  peculiar  case.  It  occtirred  in  a  woman  aged  ^3  years.  She 
had  had  profuse  muco-purulerit  discharge  from  1)oth  nnstrils  foi'  many 
years.     The  odor  was  characteristic  of  a  foreign  body. 

When  five  years  old  she  accidentally  slipped  a  thimble  into  her 
throat.  This  was  followed  by  a  violent  fit  of  coughing,  which  suddenly 
ceased  upon  her  being  thumped  upon  the  back. 


hi 


DisKASKs  or  Tiir;  ()i;()-i'ii.\i;v.\x. 


(•ii.\rri;i;  xi.ii. 

ACUTK  I'llAKVNCII  IS. 

AcuTK  sore  llirnat,  llic  cniiiiniiii  naiin'  ol'  lliis  (li.-casc,  is  of  I'rc- 
(|ii(iit  occiirrt'licc.  ]t  airc'Cts  the  whdlr  I'niirial  rcLiimi,  iiicliiilin^  tlia 
H)l'l  iKilati'.  wiih  i!ic  uvnla,  I'aiirial  pillars,  ami  tnn-ils.  'J'lic  spi)!.  first 
attacked,  ami  ri'(iiii  wiiieli  it  spreail^  to  tlie  sui'rniiiKliii'j  iis.-iies,  varies 
ill  (litrereiit  eases.  Jn  ])ers()iis  sulijeet  to  the  disiiise.  llie  |ilan  ol'  attack 
and  e.\ien.-ioii  often  i'oliows  an  almo.-l  invai'ial)le  coiii>e. 

One  ])atient  will  always  I'eol  at  the  misct  an  iiiicdiiiroi'taldc  prick- 
in.LT  soreness  in  the  one  tnn.-il.  from  wliirh  it  will  cxtiinl  to  the  wlmle 
]ihaivnt:eal  ea\ity.  Another  will  jjcrceive  tin'  lir-l  .--ynipti-m>  on  the 
hack  wall  of  the  ])liaryn\',  while  a  third  will  declare  thai  the  primary 
irritation  is  always  fell  in  the  hack  part  of  the  nn>irils  or  the  post- 
nasal spaei;.  Slill  another  will  state  po.-itivcly  that,  while  the  acute 
colli  will  always  commence  in  the  tliMUt,  il  invaiiahly  extends  npward 
to  the  nose  hefore  it  (lisap|)cars. 

Pathology. — The  nuicons  meinhrane  of  the  fauces  is  hut  scantily 
snp])lied  with  glands.  Consequently  in  the  liist  stage  of  acute  inllam- 
niation  the  S(juanious  e|)ithelial  lining  slmus  maiked  hyperaunia,  ac- 


companied with  arrest  of  secretion  and  drvness  of  the  .-urfae( 


The 


condition  may  last  twenty-four  hours  or  so,  and  is  followed  hy  ex- 
osniosis  of  serum  and  intermixture  of  nuico-jnis  and  epithelial  cells. 
Micrococci  are  present  in  large  numhers,  of  -which  stre[)tococci  in 
many  cases  predominate. 

Etiology. — While  sudden  exposure  to  a  greatly  lowered  tempera- 
ture, ])articnlarly  when  that  exposure  is  conlimd  to  certain  ])arts  of 
the  body,  will  often  he  the  immediate  cause,  yet  it  is  ])retty  generally 
conceded  that  this  rarely  occurs  without  the  jiresence  of  a  ])rior  or 
latent  cause  for  the  production  of  the  disease.  So  many  people  are 
exposed  in  a  similar  manner  without  acfjuiring  acute  pharyngitis  that 
we  are  forced  to  believe  in  a  special  tendency  toward  its  development 
in  tlie  case  of  those  who  habitually  become  victims. 

Whether  that  tendency  is  produced  hy  the  constant  presence  of 


■(^^ 


1-  ^ 

•  1    1 

232 


DISKASKS    Ol'    Tin;    I'llAICi  NX. 


iJr 


»   ' 


chronic  liiiiciiil  (li.-i';i>t',  tnii-illai'  li\  pcr|ilii^iii.  iiiiso-jiliiii'Vii,!:'!'!!!  .-((iin- 
sifi,  goucial  (lysci'aKiii,  ov  ild'aii^rcil  diuc-i idii  ur  not.  nnc  ol'  tlu'sc,  at  all 
t'Vi'iits,  hccoiiics  in  many  in.-lanco  a  |iiilcnl  Iik  tur  in  the  otiol();.ry,  anil 
if  possible  should  he  rcnioMil. 

'J'lic  altiick  may  he  iironjjlil  on  hy  cxpo^iiic  of  tlic  liaik  ol'  tin,' 
neck  or  chest  to  a  cold  wind,  |iait  icidarly  when  ihc  system  is  ovei'- 
Iieated  or  |icrs|iii'in;:.  In  ilw  >ame  way,  .-iidden  chan'ies  of  nndei- 
garnicnts  li'om  hi'avy  lo  liuht.  without  i\\\i'  rcLiaid  lo  almospherie 
temperaluic,  may  eldll  llie  snrtace  and  increa.-e  the  hUiod-pre^sui'c  in 
a  weakened  pliarynjieal  inueou-  meinhi'anc.  Tlie  disease  is  ol'icn 
caused  hy  a  vilialeil  almos[ihei'c.  iidialcd  hy  pei'-on>  employed  in  over- 
heated, ill-veiililated  rooms.  Tiic-i'  iinfoilnnates  I'reipicntly  hecome 
tile   victims. 

It  is  more  apt  to  oceiii'  in  adult  lii  ihan  amonn-  cliildrcii,  as  in 
the  hit  lei'  the  lyni|iliatie  and  ;:landiilar  eleiiiciits  are  more  prone  to 
iiillainmatory  aclioii  than  ai'e  the  conneetive-t issue  slrut-lures. 

Symptomatolog'y.  - -Slitiht  i-hilline.~-  and  Licneial  malaise,  accom- 
panied by  a  sense  ol'  discomfort  and  soreness  id'  throat,  are  usually 
the  first  symptoms.  The  rise  in  temperature  is  sli<,dit,  rarely  more 
than  one  or  two  degrees.  Frontal  headache  is  sometimes  present,  and 
when  the  inllammation  t-xtends  to  the  Mustachiau  thOes,  producing 
temporary  stenosis,  there  may  he  ringing  or  deafness. 

For  the  first  hours  the  throat  will  feel  dry  and  irritable,  and  on 
inspection  will  reveal  an  hyperannic  condition,  with  ditl'used  redness 
pervading  all  the  visible  parts  of  the  jdiarynx.  After  this  the  blood- 
vessels and  small  glands  commence  to  relieve  themselves,  hy  ])ouring 
out  upon  the  surface  a  copious  elfusion  of  sero-mucus  ;  pus-corpuscles 
may  also  develop,  and  the  inllamed  ])horynx,  coated  with  secretion, 
nuiy  in  some  places  ])c  almost  hidden  from  view,  particularly  when 
the  vanlt   is  involved. 

In  some  cases  consi(h'rahh>  o'denia  of  the  soft  palate  takes  ])lace, 
and  the  mucons  memhrane  of  the  mouth  and  tongue  i)ecome  llahhy 
and  heavily  coated  and  the  breath  itself  unpleasant.  When  the  inflam- 
matory condition  extends  downward  to  the  larynx,  an  irritable  cough 
is  induced.  This,  although  it  occurs  comj)aratively  early  in  the  dis- 
ease, rarely  extends  to  the  bronchial  tubes. 

The  duration  of  acute  pharyngitis  may  he  from  two  or  three 
days  to  a  week.  By  ])rompt  treatment  it  can  often  be  shortened  and 
the  temperature  reduced  to  the  normal,  followed  by  rapid  disappear- 
ance of  symptoms. 


()1{U-1'1IAUVN\.       ACrii:    I'll  VKVSdl  I  IS. 


•y.VA 


,. 


Diagnosis.  Snic  tliioat,-  (uriir  in  coimcctinii  with  ,  Niiiitliciiiatniw 
(liscii.-cs.  ,'iihI  in  these  ciists  thi'  (liiijiiiDsis  nmv  lu'i  he  ccrtiiin  until  thr 
hnrfiicc  ciiiiitiiin  apiicars.  Slill.  <•!((.■-(■  cxaininaliiin  >liunhl  (li.-tin,Lj,iiish 
tlio  even  h_v|icra'niia  <>{'  sini)i|c  .^nic  ihi'nat  I'rniii  ihc  -iihnniiiiii<  I'lHoroi:- 
ecncw  (if  llic  ciiiiitivr  r  vcr.-.  In  ciininii'iicinj;  t(»nsillitis  the  pain  (if 
tlio  tnn^il  aH'cdi'd  is  nimc  scmii'  than  in  siinjilc  acute  pliann^iti.- 
while  the  redness  of  the  suri'du'iHlinij:  niuen.^a  is  h'ss  evenly  distrihnteil. 
Jn  rlienuialie  Mire  tliinat  tiiere  is  u.-iially  h's-  ledenia  than  in  the 
second  .-laue  nj'  tjii-  disease^  wjiik'  tlie  t'aueial  mnscK'S  are  nmre  pain- 
ful. 

Prognosis. —  rnle>s  the  inlhiininatmy  adidn  extends  [n  the 
larynx,  it  usually  snhsides  within  a  week.  Siuur  wiiteis  have  re[i(»rted 
cases   |nll(i\.ed   l)y  .systemic  paialy>is,  luil    it    i»  dniditl'ul   wludhiM'  the 

toxic   eireet    iif    the   ili>caM'   cuuld    Ih'   SeVele   ellnllLlh    li'    pi'nduce    pai'csis. 

Other  writers  helievu  that  these  must  ha\e  heen  casesj  ol'  masked 
diphtheria,  in  which  the  Klelis-Ldelller  haiillus,  althnnii'h  lu'csent, 
could   nut   he   t'dund. 

Treatment. —  Uefore  cnicrini:-  upon  the  treatment  <d'  acute  iihar- 
yni^itis  a  wnrd  i<v  twd  mii^ht  lie  >aid  here  in  refercnee  to  euraiiie. 
intrndnced  a  cnnple  u\'  years  a,i:i)  as  a  enHatei'al  dru;_r  which  nii,L;ht 
ill  some  cases  take  the  jilace  ot'  cocaine  in  tlie  treatment  (d'  iinx' 
and  throat  diseases.  1  have  lud  spoken  ol'  eucaino  before,  because 
from  the  writini;s  of  authors  and  my  own  porsnnal  oxporience  I  did 
not  think  it  cnnid  be  \\>v(]  with  advaiitauf  in  nasal  work,  and  in  this 
field  would  be  i'ar  inlVrinr  in  idility  to  cocaine  as  a  local  amrstbotic. 
In  the  pharynx,  wbero  we  have  ample  sjiace  for  vision,  and  do  not 
re([uiro  to  contract  the  tissues  in  order  to  obtain  a  view,  the  case 
may  l)o  dilferent,  and  I  will  bore  pive  the  views  of  several  leading 
writers  upon  tlio  comparative  merits  of  the  two  drugs. 

Soniers  {Thcmpeulic  Gazelle)  says  cocaine  produces  local  anirs- 
tlicsia  in  from  .'?  to  5  minutes,  lasting  from  20  to  30  minutes;  eucaino 
produces  local  ana>stbesia  in  from  S  to  10  ininufcs  lasting  only  20 
minutes.  Cocaine  produces  ana-niia  of  iniicous  membrane.  Kucaine 
produces  hypera'inia.  This  action  of  eucaine,  he  says,  strongly  mili- 
tates against  its  use  in  operations  upon  byperlropbie  tissues.  The 
advantages,  however,  wbicb  it  lias  over  cocaine  are  the  following: 
It  produces  less  pbaryngeal  disturbance,  is  less  harmful  to  tlie  system, 
keeps  better  in  solution,  and  tlie  efTlciency  of  tlie  drug  is  not  injured 
by  boiling. 

Poucbet  (La  Semaine  Medicale),  reporting  to  tbe  Societe  Tbera- 


I'd 

i            ' 

23i 


UlSKASES    OF   THE    rUAliVNX. 


})eutiquc,  said  that  lie  liatl  investigated  tlie  physiological  action  of 
oucaine.  He  found  the  toxic  equivalent  almost  equal  to  that  of  co- 
caine, lie  sa3s  eucaine  may  produce  toxic  ell'ccls,  whicli  may  even 
])rove  fatal  witliout  any  prodromie  stage.  Its  action  on  the  heart  is 
as  intense  as  that  of  cocaine.  Eucaine  must  therefore  be  looked  upon 
as  a  dangerous  drug. 

Keclus  (lirilish  Medical  Journal  J'JpiloDw)  says  that  in  equal  doses 
its  anitsthetic  ]io\vcr  is  less  than  that  of  cocaine.  He  thinks,  there- 
fore, that  it  i^liould  not  be  used  in  serious  oj)orations. 

J.  S.  (iihl)  {Philadelphia  Poh/clinic)  has  used  eucaine  in  diseases 
of  nose  and  lliroat,  and  sums  up  as  follows:  L  Kucaine  is  ecjually 
elliciont  witli  cocaine  a-  an  anaesthetic  in  ordinary  examinations.  2. 
It  possesses  e(iual  ana}stlielic  power  with  cocaine  aiul  hence  is  as  use- 
ful in  o])erations  on  nose,  throat,  and  laiyiix.  .'!.  luicaine  is  nearly 
if  not  quite  as  effective  as  cocaine  in  reducing  the  engorged  turbinated 
bodies.  4.  Kucaine  is  su]ierior  to  t-ocaine,  in  thai  it  is  less  likely  to 
produce  toxic  symptoms  and  also  unpleasant  subjective  symptoms, 
particularly  as  regards  the  pharynx. 

f.asily,  Jobson  Home  and  MacLeod  Yi'arsly  [JiritisJi  Medical 
Journal),  'fler  a  long  article  u])on  the  subject,  close  with  the  follow- 
ing sti  lenient:  "Several  points  I'cniain  for  furtlicr  experience  to 
decide,  out  ws  consider  lliat  our  results,  so  far,  justify  us  in  con- 
tinuing the  investigation.  luicaine  cannot,  however,  wholly  replace 
cocaine,  since  the  eU'eet  of  the  latter,  in  reducing  the  size  of  the  tur- 
binated bodies,  gives  it  a  value  as  an  aid  to  diagnosis  which  eucaine 
does  not  appear  to  possess." 

These  combined  remarks  seemingly  would  justify  our  exclusion 
of  eucaine  in  dealing  witli  diseases  of  the  noK^;  while  they  indicate 
a  probable  utility  in  regard  to  the  treatment  of  pharyngeal  disease. 

To  return  to  the  treatment  of  acute  pharyngitis.  ^I'.ch  can  be 
done  in  the  way  of  aljortive  treatment  in  tbe  ]ihysician's  ofllce.  It 
can  fre(|ncntly  be  arrested  by  prompt  local  treatment.  First,  cleanse 
the  ]>]iarynx  with  a  spray  of  Hobell's  solution.  Then  spray  it  at  once 
with  a  Iv-pcr-cent.  solution  of  cocaine.  Pos>il)ly  a  similar  solution  of 
eucaine  would  answer  equally  as  weP..  This  will,  in  a  few  moments, 
deaden  the  terminal  ner.'c-filaments  and  prepare  the  mucous  mem- 
brane for  the  im.|)ortant  jiait  of  the  treatment,  which  is  simply  to 
brush  the  pharynx  with  a  5-per-cent.  solution  of  nitrate  of  silver, 
applying  the  pigment  most  thoroughly  upon  the  parts  afTected.  The 
treatment  is  to  be  repeated  in  twenty-four  hours  if  required.    In  the 


OKO-1'HAUYNX. 


ACUTE    l'liAHYN(iniS. 


nieantiinCj  and  subsequent  to  the  brusliin<3%  oitlier  of  the  I'oUowing 
solutions,  applied  with  an  atomizer  every  three  or  four  hours,  will 
act  as  an  antiseptic  to  the  throat  and  aid  in  keeping  it  clear  of 
catarrhal  secret iojis: — 


i : 


1.  It  Ixi'sortin    112 

Glycerin    Gl 

Aqiiam     iid  GOI 

M. 

2.  IJ  Tliyinol    1005 

Boric  acid   2! 

Glyicrin    15 

Aquani    ad  GO 

M. 

Although  by  tnis  method  slightly  increa.-^ed  tenderness  of  the 
throat  may  be  experienced,  as  soon  as  the  eil'ect  of  the  cocaine  or 
eucaine  has  ])assed  away,  yet  the  course  of  the  disease  will  be  short- 
ened. In  a  day  or  two  the  increased  redness  of  the  mucous  membrane 
will  have  disapyicarcd,  and,  instead  of  the  pultaceous  inliltration  and 
muco-purulent  discliarge  that  sometimes  occurs,  it  will  have  resumed 
an  almost  normal  appearance. 

To  accomplish  the  same  object  in  a  dilTei'ent  way  JMshop  advises 
tlie  administration  of  pelk'ts  each  containing  ^/„  milligramme^  of 
atr(i])ia  and  8  milligrammes''  of  morphia,  repeated  every  few  hours 
as  required,  to  act  by  their  combined  anodyne  and  drying  efTect  uptm 
the  mucous  membrane. 

Quinine  might  be  administered  in  either  ease  and  a  brisk  cathar- 
tic if  required. 

Amniig  the  older  methods  of  treatment,  one  that  has  often  been 
very  ell'ectivc  in  checking  the  disease  is  the  giving  of  drop  doses  of 
tincture  of  aconite  every  hour  until  the  throat  symptoms  commence 
to  abate,  after  wliich  the  interval  should  be  lengthened.    This  would 

1.  B  Krsnrcin    ffr.  xviij. 

(ilyccriu    3iss. 

A(iuaiii    ad  .'^ij. 

2.  R  Thyiiiol    !-'r.  j. 

Horic   acid    ;;r.  xx.x. 

•  .lyccrin    Hixlv. 

Aiiiiiiiii    ad  Sij. 

M. 

'  V(M  grain.    •  '/«  grain. 

IS 


I    -',*:. 


I  ':    .ft-   i 


III 


!  ly- 


^3 


li: 


23G  DISKASICS    01''    TIIK    IMiAUYNX. 

usually  occur  before  the  first  tweut^'-l'our  doses  luul  been  given. 
Tincture  of  belladonna  might  be  prescribed  in  the  same  way,  in  ;?- 
drop  doses  every  two  hours.  Jiotli  are  arterial  sedatives,  with  an 
astringent  cfl'ect  upon  the  fauces. 

(iarglcs  of  alkaline  solulir.ns.  such  as  Diiliell's,  chlorate  nf  potassa, 
etc.,  have  long  been  advised  in  tin'  ircatment  of  this  disease,  (largles 
are,  however,  as  a  rule,  only  iinpcrft'ctly  applied,  the  solution  not 
being  allowed  to  enter  the  lower  {)haryn\  at  all.  ('onseipiently,  even 
when  using  the  same  solution,  a  good  atomizer  is  much  to  ho  pre- 
ferred. 

]f  the  ini])rovciucnt  seems  tardy,  the  alkaline  spray  niighi  be  fol- 
lowed by  an  astringent,  my  own  preference  being  for  the  liydi'ocarbon 
C'ompnnnd,  used,  of  course,  with  an  atomizer. 

1.  IJ   .Acid,    taiiiiie 2| 

(Jlyccriii     31 

A(piiuii    ad  GOI 

At.  ' 

2.  H  ThyiiKil    |]3 

Moiithol  113 

.•Vlbolcnc    OOJ 

M. 


As  regards  external  applications  to  I  he  nock,  1  do  not  believe 
they  are  of  much  value.  Sometimes  a  enld  wei  flaniu'l  applied  to  the 
front  of  the  throat,  and  kept  in  position  by  a  rubber  bandage  around 
the  neck,  wdl  reduce  the  irritation  by  its  sedative  elTect.  When 
counter-irritation  is  needed.  ei|ual  parts  of  spirit  of  iuriicntine  and 
sweet  oil  form  a  good  application,  the  throat  being  covered  witli  a 
layer  of  cotton-wool. 

As  said  before,  persons  subject  to  this  di.sease  arc  frequently 
sufferers  from  some  obstructive  lesion,  which  is  the  primary  cause. 
Ifence,  after  recovery,  it  is  the  duty  of  the  jdiyt'cian  to  see  to  it  that 
the  lesion  if  present  be  removed,  and  that  the  entire  naso-pharyngeal 
mucosa  be  ])laced  in  as  souiul  a  condition  as  possible. 

1.     It   Acid.  t;iiiiiif pr.  XXX. 

(Glycerin    »/ixlv. 

A<ni;iiii    ad  ,^ij. 

'2.     It  'riiyitiol    gr.  ij. 

Mciiduil    pr.  XX. 

.Mliolcnc    3ij. 

]M. 


CllAi'TKll  XLlll. 


ciiiioxic  I'liAiivxcnis. 


J 


This  (lisca-^L'  is  coiiiincd  lai\i:cly  in  tin:  pharviiiifal  iiiiicoiis  nieni- 
braiie,  the  .-ol'l  ))alatt'  aiul  tlic  uvula  In'iiig  rarely  alVectcd,  oxt-cpt  in 
cast's  wliicli  have  a  nasal  oriuiu.  As  it  (ncurs  cliiclly  in  adult  life, 
the  j^landular  systcMn  is  lint.  littU'  ad'cctcd.  The  tonsils,  however,  if 
in  an  liyper^jlastie  condition,  not  infrequently  hcconie  atl'ected  l)y  the 
disease. 

Pathology. — Successive  I'ejiet  it  inn  of  ailaek-  of  soi'e  throat,  from 
whatever  cause,  is  likely  to  produce  peimauent  hypera'niia  and  relaxa- 
tion of  the  hlood-vossels.  A  species  of  pliarytiLreal  paresis  takes  phice 
—the  cnntinned  coni^-estinn  rcsnltincj;  in  surfaee-intiltratinn  and  struct- 
ural thickening''  of  the  mucosa.  The  lymph-follicles  and  muciparous 
glands  arc  also  alVecled,  sometimes  hciug  marked  hy  distinct  hy[)er- 
tro])hy  in  the  lines  (if  the  salpinu^o-pharyngeal  folds. 

Etiology. — There  are  many  canses  for  this  disease,  and  writers 
in  tracing  out  the  etioloiry  are  ai)t  to  be  indneiiced  !)y  special  features 
coming  imder  their  ])ersonal  ohservatiou.  in  my  own  experience, 
chronic  nasal  disease,  d(>viations  of  the  septum,  the  presence  of  neo- 
plasms, or  post-nasal  adenoids  have  heen  the  ])i'evailiu'^-  causes.  The 
result  of  any  of  these  would  he  oral  Itrcathinir,  particularly  at  ni.^ht, 
and  the  direct  contact,  repealed  every  ni<:ht  for  a  prolonjied  period, 
of  dry  air  upon  the  post-pharynx,  for  reasons  already  explained, 
would  he  suHicient  to  induce  the  ilisease. 

Home  writers  believe  that  the  nuist  comnuui  cause  is  the  occui- 
renco  of  the  ofl-repeat(>d  attacks  of  acute  pharyii'iit  is,  while  otheis 
as«ert  that  tliis  is  never  the  cause,  hut  that  the  chronic  disease  is  the 
etiolo,<,ncal  factor  of  the  acuje. 

liosworth  traces  tlie  disease  to  chrnnie  ^lastrilis  of  one  form  or 
another,  hasin;^'-  the  he]ief  on  the  theory  that  the  lu-o-pharynx  i-  a  part 
of  the  food-tract,  and  conse(|uently  nmre  in  sympathy,  physioloirically 
and  patholoirically.  with  the  diixesiive  than  the  respiratory  organs. 
Castric  disturliances  of  a  chronic  cliaracter  almost  invariably  atVect 
the  pharynx,  possil)ly  by  retlcx  influence.  This  is  particularly  th(> 
case  in  chronic  alcoholism.    The  tobacco  habit,  too,  is  not  unattended 


If 


ill' 


238 


DISEASES    OF    TJIE    TJIAUYNX. 


by  evil  results,  though  whetlier  they  arise  from  nicotine  ahsori)tion 
or  the  direct  efl'eet  of  tlie  hot,  dry  air  upon  the  throat  is  still  an 
undecided  question.  Persons  wliose  oecujiations  keep  tlieni  exposed 
to  constant  respiration  of  foul  air  or  irritating  gases  are  also  subject 
to  the  disease.  Jt  is  also  frequently  caused  by  improper  or  prolonged 
use  of  the  voice. 

Symptomatology. — A  sensation  of  iluoat  discomfort,  accom- 
panied by  a  desire  to  swallow,  in  (jrder  to  relieve  the  parts  of  sup- 
posed accumulations,  is  one  of  llie  coiumonest  symptom.-,  particularly 
when  the  disease  has  a  nasal  origin.  When  it  arises  from  chronic 
gastric  disturbance,  tiie  throat  is  more  irritable,  and  on  examination 
with  the  tongue-depressor  retelling  may  be  produced,  while  the  raw, 
inflamed  condition  of  the  lower  jiharynx  will  ))e  ol)sorvcd.  The 
voice,  too,  is  often  altcri'd  in  Iniic.  'I'licrc  may  he  a  ras[)ing  screatus 
to  clear  the  lower  ])liaiyn\.  and  a  jfrky  hnarseness,  sometimes  lapsing 
momentarily  into  aphonia.  A  voluntary  cough  to  free  the  arytenoids 
from  mucus  may  l)e  jircsent.  In  certain  cases  the  palate  becomes 
relaxed,  hanging  down  like  a  llabby  curtain,  ami  even  the  uvula  may 
become  o'dejnatous  and  elongated,  though  these  conditions  can  only 
occur,  I  Ijclieve,  when  the  primaiy  cause  lies  in  the  upper  air-passages. 

Diagnosis. — The  symjjtoms  described,  together  with  the  sensa- 
tions experienced  Ijy  the  ])atient,  should  easily  distinguish  this  from 
any  other  disease.  The  chief  dilliculty  in  diagnosis  sboidd  not  be  as 
to  existence  of  chronic  pliaryngitis,  but  as  to  the  catise  which  pro- 
duced it,  whellicr  it  arose  fiiun  gastric  or  nasal  disturbance  or  from 
some  purely  external  source.  One  broad  distinction  lies  between  the 
first  two.  In  tlu!  former  the  lower  throat  will  be  deeply  congested  and 
the  tongue  will  be  irritable,  with  red  ]iapilla3  stamling  over  its  base, 
ibe  jialate  being  1)iit  slightly  all'ected.  In  the  latter  the  redness  and 
irritahilily  will  he  slighter,  the  post-])haiTnx  l>e  more  deeply  coated, 
and  the  ]ialate  alTected  more  or  less  by  the  disease.  When  both 
these  causes  can  be  excluded,  the  history  of  the  case  per  se  may 
indicate  the  origin. 

Prognosis. — This  i-  not  an  alarming  disease;  but,  as  the  cause 
])roducing  it  is  usually  of  a  chronic  character,  both  chronic  condi- 
tions rccpiire  to  be  removed,  and  it  may  take  careful  treatment  for 
a  long  time  to  accomplish  the  end  in  view.  Still,  much  relief  even 
from  the  commencement  can  be  given,  and  it  is  worth  the  patient's 
while  to  submit  to  the  necessary  treatment. 

Treatment. — When  the  disease  is  secondary  it  becomes  important, 


()I{()-l'IIAIiVN\.       fltKONIC    I'llAUYNdll  I>. 


^39 


if  possililc.  111  rciiKivc  the  jiriiiuirv  ciiusi',  wlidlici'  thai  lie  \i\  >iii'^ical 
removal  of  ol)sti'iictivc  lesions  of  nose  or  iiaso-jiliaiTiix  or  systrinic 
treatment  of  clironie  gastric  disease.  It  may  lie  necessary  \n  lurak 
or  check  the  liquor  hahit  or  to  interdict  the  use  of  tohaceo.  DilVnult 
as  either  of  the  latter  may  seem  to  be,  llie  patient  who  appreciates 
the  throat  all'ccjion  sullicicntly  to  seek  professional  relief  will  usually 
do  his  liest  to  carry  nut  the  physician's  advice. 

Direct  trcalnient  to  (he  throat  will  also  he  reijuired.  The  r!r,>t 
should  he  ihorouiih  cleansiufr  with  alkaline  sprays.  If  there  is  much 
fhickeninp-  and  infiltration  of  the  mucosa,  this  should  he  followed  liy 
the  application  of  a  10-per-cent.  s(dution  of  nitrate  of  silver.  The 
best  way  of  a])plying  it  is  by  means  of  a  cotton-holder.  Sometimes 
the  throat  is  so  iriitalile  that  the  pressure'  of  the  tongiu'-depres-or 
upon  the  hack  of  the  tongue  will  immediately  produce  contraction 
of  the  pillars,  shutting  off  almost  the  whole  of  the  post-pharyngeal 
wall  from  view.  To  obviate  this  a  weak  sulution  (if  cocaine,  1  or  2 
per  cent.,  nuiy  be  applied  to  the  fauci's.  Then,  in  applying  the  silver 
solution,  the  eiul  of  the  holder,  aftrr  b!'u>liing  th<'  part  of  the  })ost- 
pharynx  in  view,  sluuild  he  lient  to  an  aiigh'  of  loO  degrees  or  so,  and 
slipped  behind  the  posterior  pillar  on  one  side,  and  glided  up  aiul 
down  to  the  full  depth  of  the  fold,  the  other  side  being  treated  in 
the  same  way.  This  treatment  need  not  be  repeated  oftciu'r  than 
once  or  twice  a  week  at  the  physician's  nllice. 

Other  astringents — such  as  sulphate  of  cojiper.  chlnride  of  zinc, 
glycero-tannin,  etc. — might  be  used  instead,  but  for  directly  removing 
the  ontside  coating  of  the  mucous  membran(\  and  stimulating  normal 
action  of  the  capillaries,  no  application  ap[)ears  to  act  as  ethciently  as 
nitrate  of  silver. 

For  luuuc-lreatment  the  patient  should  spray  the  throat  freely 
twice  a  day  with  an  alkaline  solution,  and  follow  this  each  time  by  one 
of  the  hydrocarbon  preparations  already  mentioned,  «uch  as: — 

3-per-cent.  camphor-menthol  in  albnlene. 
o-per-cent.  eucalyptol  in  albolene. 
3-per-ccnt.  menthol  in  alboleiu3,  etc. 

The  general  system  should  also  be  regulated,  the  alimentary  canal 
attended  to,  and  apjiropriate  tonics  prescribed  if  necessary. 


;        .] 

'  ]        i 

I  !•  :i! 


t  1. 


!  n 


i  liii 


CHAPTEK  XLIV. 


FOLLICULAR  PHARYNGITIS. 


!  ; 


ili 


This  disease,  as  its  name  implies,  is  confined  to  tlio  follicles  of 
tlie  pharynx,  particularly  to  those  of  the  post-pharyiigeal  wall.  Tlie 
inllammatory  process,  without  extending  to  the  wliole  mucous  surface, 

scattered  over  the 
cted  follicles  vary- 


oduces  hyperj)lasia  in  a  number  of  isolated  spots 

and  location  of  the  affe 


luces 
membrane. 


th 


le  abundance 
ing  in  dill'erent  cases. 

Pathology. — The  lymph-follicles  involved  in  this  disease  are  en- 
larged and  stand  out  prouiinently  above  the  surrounding  mucosa. 
While  the  mucii)arous  glands  are  few  upon  the  pharyngeal  wall  and 
tlic  lymph-follicles  widely  scattered,  yet  it  api)ears  to  be  those  situ- 
ated in  the  immediate  vicinity  of  tlic  glands  that  have  tlie  greatest 
tendency  to  hypertrophy.  Tiie  morbid  process  consists  of  abnormal 
deposits  of  lyin])h-clenK'nts  accompanied  by  epithelial  growth.  In 
the  exudative  form,  instead  of  tlie  latter  develo))nient,  the  follicular 
tul)ules  are  distended  by  a  cheesy  secretion,  which  exudes,  and  may 
crust  upon  the  surface.  In  some  cases  the  inflammation  becomes 
more  diffuse.  A  niinibcr  of  follicles  will  be  united  by  connecting 
submucous  hyperplasia,  and  plaques  are  found  varying  in  size  rising 
above  the  niueuus  mcml)raiu'.  "When  the  disease  occurs  in  early  life, 
tlie  granulations  are  soft  and  sometimes  large;  but  as  they  rarely 
disappear  of  themselves,  they  undergo  a  change  as  the  patient  gets 
older,  becoming  smaller  and  more  dense  in  texture.  Sometimes  the 
hypertrophy  of  the  follicle  is  associated  with  atrophy  of  the  surround- 
ing mucosa.  In  others  there  are  not  only  the  isolated  granulations  of 
the  central  wall,  but  also  strings  of  thickly-studded  lateral  granula- 
tions extending  upwaid  into  the  naso-pharynx.  behind  the  posterior 
jiillars  of  the  fauces. 

Etiology. — I'lxcept  in  the  two  extremes  of  life,  during  which 
l)eriods  the  disease  is  almost  unknown,  age  has  little  influence  in  pro- 
ducing it.  It  occurs  from  childhood  all  the  way  up  to  middle  age. 
In  early  life  wlien  adenoids  are  present  we  would  naturally  expect 
these  granulations  to  oecur  in  conjunction  with  them,  the  adenoids 
being  the  cause,  not  by  dirt'ct  extension,  but  hy  pro(lueing  throat 
(•MU) 


ORO-PIIAKYNX.       I'OI.LICILAU    I'M AUYNdlTIS. 


•^11 


irritation  consequent  to  oral  breathing.  The  rorniation  di'  adenoiils 
and  follicular  disease  are  both  influenced  in  many  cases  by  the  pres- 
ence oi'  scrofulous  diatliesis.  In  adult  life  it  frequently  occurs  as  a 
result  or  coni])lication  of  previously-existing  nasal  disease. 

It  is  said  to  occur  more  frequently  among  wniucn  than  men, 
probably  owing  to  the  more  sedentary  occupations  oi'  the  former,  and 
the  consequent  greater  tendency  to  the  dcvelDpmciit  of  disease  of  the 
mucous  membrane.  We  should  remend^er,  also,  how  much  the  phar- 
yngeal mucosa  is  inlluenced  by  the  gynjecological  condition  of  the  sex. 

Granting  a  tendency  toward  the  disease,  breaihing  a  dusty  at- 
mosphere, excessive  use  of  the  voice,  continued  nasal  ol)struflion,  the 
occurrence  of  acute  or  chronic  pharyiigitis,  or  any  other  comlitions 
which  may  imluce  continuous  throat  iiritution  may  irsull  in  the 
development  of  pliaryngcal  granulations. 

Symptomatologfy. — When  occurring  in  children,  the  symptoms 
are  rarely  noticeable,  being  thrown  entirely  into  the  shade  by  the 
existing  primary  disease.  In  adult  life  this  is  dilferent.  The  suii- 
jectivc  sensations  are  more  intelligently  realized.  Tlie  nasal  stenosis 
or  post  pharyngeal  discomfort  may  have  been  relieved,  but  the  dry- 
ness and  pricking  sensations,  and  hacking  cough  ])roduced  by  the 
presence  of  the  granulations  are  still  there,  producing  annoyance  and 
discomfort  to  the  patient.  The  voice  loses  its  full  aiul  rounded  tone 
and   is  easily  fatigued. 

^\'hen  the  disease  is  associated  witii  post-nasal  catarrh,  the  pos- 
terior wall  of  the  pharynx  may  l)e  covered  with  a  grayish,  stringy 
coating  of  mucus-pus,  often  hiding  the  granulations  from  view  until 
it  is  removed.  Then  the  surface  will  he  seen  more  or  less  covered 
with  promineiit  little  hypertrophies.  They  vary  from  one  to  live 
millimetres  in  diameter,  and,  when  phniiies  are  present,  they  some- 
times cover  from  one-half  to  one  s(|uaro  centimetre  in  area. 

Although  strings  of  granulations  may  sometimes  l)e  observed 
running  upward  behind  the  pillars  into  the  naso-])harynx,  it  is  com- 
paratively rare  to  find  the  posteiior  pillars  affected.  When  they  do 
form  on  the  pillars  or  the  margin  of  the  velum  or  uvtda,  the  granu- 
lations arc  very  small  and  hard,  like  little,  red  seeds,  standing  out 
upon  the  mucous  mend)rane. 

Stiffness  of  the  throat,  painful  deglutition,  aiul  sori'iu'ss  after 
prolonged  speaking  are  freciucnt  symptoms,  and  have  given  I'ise  to  the 
term  "clergyman's  sore  throat"  which  has  often  been  applied  to  it. 
The  application  seems  to  be  an  unfortunate  one.  a-;  the  sore  throat 


!      Ui 


ifi 


M 


2[\ 


DISEASES   OF   THE    PKARYNX. 


I  r 


by  which  so  many  clergymen  arc  affected  is  almost  always  due  to  other 
cau?es.  This  was  particularly  exemplified  in  a  paper  which  I  read 
before  the  Canadian  Medical  Association  ir  M(mtrcal  in  August,  189G, 
giving  the  history  of  10  cases  of  so-called  clergyman's  sore  throat. 
Allhougli  it  is  a  slight  digres<;ion,  yet  it  has  a  bearing  upon  tiio 
subject,  and  the  quotation  of  the  last  few  sentences  will  not  be  out 
of  place: — - 

"In  conclusion,  according  to  old  ])arlancc,  the  10  cases  I  have 
reported  niii;lit  all  be  called  'clcigvuiiui's  sore  thrnnt.'  wliil(>  in 
reality  only  2  had  follicular  pliaryiigilis.  All  had  soi'cness  and  hoarse- 
ness in  a  more  or  less  degree;  hut  these  sym])toms  arose  from  widely 
differeiil  causes,  and  in  several  instances  hypertrophies  of  different 
kinds  wore  found  to  exist  in  the  one  case. 
"Jirielly  to  epitomize: — 

In  1  there  was  a  large  nasal  y)olypus. 

In  1  a  dislocated  columnar  cartilage. 

In  1  hypertropliy  ol'  the  faucial  tonsils. 

In  1  ulceration  of  the  hyoid  fossa. 

In  2  there  were  septal  ridges. 

In  2  septal  s]uirs. 

In  2  cntarrhiil  li\'pci'lro|ihi('<  of  the  i)ost-seplum. 

in  2  clongalion  of  the  uvula. 

In   2   |iharviigcal   granulalious. 

In  .")  turhiual  h_vperiro])hi('S. 
"While  in  only  oni'.'  and  that  the  most  serious  case  of  all,  was 
there  uneoni|dieated  laryngeal  disease." 

Whether  a  name  which  will  cover  sueli  a  variety  of  diseases,  merely 
because  one  or  two  symptoms  may  be  present  in  all,  is  worthy  of  a 
place  in  medical  literature  is  at  least  doubtful. 

Diagnosis. — Carefid  exaniiiuition  by  means  of  the  head-mirror 
and  relleci(v]  light  should  at  once  exclude  every  other  disease.  The 
little,  round,  red  or  grayish-red  spots,  shining  brightly  upon  a  ]ialer 
background,  could  not  he  mistaken  for  anything  else.  When  the  sur- 
face is  coati'd  from  post-pharyngeal  catarrh  the  spots  may  be  hid, 
but  clearing  tliis  away  by  the  use  of  an  alkaline  spray  will  soon  render 
them  visible,  together  with  any  plaques  or  lateral  granidalions  that 
may  be  present. 

Prognosis. — This  is  usually  a  chronic  disease,  and  rarely  subject 


'  Eijilitccii  iiKiiillis  later  lliis  gentleiuan  died  of  malignant  disease  of  the 
larviix. 


OHO-rilAUYNX.       I'Ol.l.ICI  l.AU    I'llA  H  VMUTIS. 


•v'4;5 


to  spontaiu'ous  cure,  cxicj)!  as  iiicideiitiil  to  llie  lyni|iliati('  atrophy, 
coninion  in  old  aj,fe.  Be:>idcs  the  annoyance  it  causes,  in  persons  wlio 
do  not  rc([uirc  to  use  the  voice  unusually,  its  presence  may  be  of  littli! 
moment.  In  voice-users,  liowever,  whether  public  speakers  or  sin<;ers, 
the  presence  of  l'(jllicnlar  pharynLritis  becomes  a  serious  matter,  as 
it  interferes  with  the  tone  and  ([uality,  as  well  as  tlie  endurance,  of 
the  voice  itself.  Fortunately,  however,  it  is  amenable  to  treatment 
in  a  liii'.ire  majority  of  cases. 

Treatment. — This  consists,  after  cleansing  the  pharyn.v  of  all  se- 
cretions by  the  free  nse  of  ?prt.ys,  in  destruction  of  the  hypertrophic,* 
follicles  one  by  one.  For  this  purpose  many  methods  have  been  ad- 
vised, the  object  being  to  destroy  the  overgrowth  without  injuring 
the  surrounding  healthy  tissue.  London  paste  and  diroinic  acid  are 
both  used  for  this  purpose.  The  chief  objection  to  each  is  the  possi- 
bility of  the  extension  of  the  effects  of  the  agent  to  the  adjoining 
mucous  membrane.  The  galvanoeautery-puint  carefully  used  is  en- 
tirely free  from  this  objectionable  tendency. 

Although  the  operations  are  slight,  and  the  pain  of  burning  re- 
duced to  a  minimnm,  it  is  always  Ijetter  to  precede  the  operation  by 
the  application  of  a  solution  of  cocaine  to  the  ])harynx.  Some  oper- 
ators consider  this  unnecessary.  Still,  the  fact  that  the  deadening  of 
the  pharyngeal  wall  prevents  the  reflex  contraction  of  the  posterior 
pillars  during  the  operation  makes  it  almost  im])erative  to  use  it.  At 
the  first  sitting  three  or  four  or  half  a  dozen  granules  may  be  touched. 
The  operations  should  be  repeated  at  intervals  of  three  or  four  days 
until  all  have  been  removed.  A  mild  spray  of  V„-pcr-cent.  solution 
of  thymol  in  albolene  iised  several  times  a  day  by  the  patient  will 
have  a  soothing  influence  during  the  course  of  treatment.  If  ca- 
tarrhal secretions  interfere,  they  can  be  removed  by  an  alkaline  spray 
instead.  The  kind  of  electric  point  used  should  depend  on  the  size 
and  shape  of  the  granulations,  and  the  heat  should  not  be  so  great 
as  to  produce  luvmorrhage.  The  small-pointed  hypertro|)hies  would 
require  the  needle-pointed  electrode,  the  larger  ones  a  thicker  ti]i, 
and  the  plaqiics  may  be  incised  at  a  dull  heat  from  side  to  side  with 
]iarallel  cuts — the  whole  surface  not  being  destroyed  at  one  time. 
There  is  alwa^'s  more  or  less  inflammatory  action  afterward,  and  it  is 
always  better  so  to  operate  as  to  keep  reaction  at  a  minimum  point. 

If  the  granulations  are  very  numerous  the  treatment  should  be 
prolonged  and  sometimes  intervals  of  weeks  might  be  allowed  to  pass 
between  the  cauterizations. 


■■  ■ 

:  1  . 
illt 

iii: 


in 


I 


844 


DrSEASKS   OF   THE    I'HAKVNX. 


Of  coiirso,  if  the  disease  owes  its  orij^Mn  to  nt'()|iliisiiis  or  ovor- 
growtlis  ill  (Ik;  upper  ri.'S])iratory  passages,  these  should  ho  removed 
heforo  the  patient  is  dismissed  from  treatment.  Any  deran;.fement 
of  the  system  should  also  Ik;  reetilied  iiy  judicious  medication,  to- 
gether with  attention  to  diet  and  hygiene. 


CIIAPTKR  XI, V. 


ACITK  TONSlLl.mS,  OH  QL  IN-SV. 


:*■ 


^1  !i 


The  close  observation  with  which  this  iliseasc  has  been  observed 
<Iurin<f  recent  years  lias  e.'^lablir^lied  the  fact  tiiat  although  tlie  tonsil 
j)artakes  in  the  acute  inllaniniation  which  is  developed,  in  a  large 
proportion  of  cases  the  di.-case  originates,  not  in  the  tonsil  itself,  but 
in  the  areolar  tissue  surrounding  it.  Still  ilicie  can  be  little  (Iduhi 
that  many  cases  occur  in  which  the  inllanimaiory  action,  if  nut 
virtually  confined  to  the  tonsil,  at  least  has  its  origin  there. 

JJosworth  believes  that  all  cases  of  quinsy  are  |)eritonsillar  inthiui- 
nuitions  of  areolar  tissue;  Cassellierry  cipially  I'a.ors  this  view.  'I'iu' 
older  writers,  and  ]>ishop  among  the  new  ones,  claim  the  condiliou 
as  one  of  amygdalitis,  or  abscess  of  the  tonsil  itself,  and  an_\  peri- 
tonsillar extension  to  be  of  a  secondary  character.  In  Lennox 
Browne's  experience  oo  per  cent,  of  cases  occur  in  the  lacun;e  of  the 
tonsil,  28  ])er  cent,  in  the  ])areiichynui,  and  only  i:')  per  cent,  in  the 
peritonsillar  tissue. 

From  my  own  experience,  I  believe  the  (U'igin  may  he  cither 
cxtratonsillar  or  intratonsillar.  '^rii(>  deep  i)hlcgmonous  abscess,  in- 
volving all  the  peritonsillar  tis>ues,  with  the  whole  lateral  wall  stand- 
ing out,  and  pressing  the  tonsil  itself  directly  across  the  i'aucil  cavity, 
may  in  every  instance  be  peritonsillar  in  its  oi'igin;  but  others,  which 
are  oft-recurring,  definitely  localized,  and  arutely  painful,  in  which 
the  most  marked  ocular  signs  are  in  the  tonsils  themst'lves.  are  likely 
to  be  tonsillar  in  their  origin,  any  extension  into  the  siiriounding 
tissues  being  of  a  secondary  character. 

If  not.  it  might  be  asked,  how  is  it  lliat  in  the  latter  class  of 
cases  the  tonsils  themselves  steadily  increase  in  size.  l)ecoming  larger 
and  larger  with  each  successive  attack,  while,  so  far  as  can  be  seen, 
the  Pin-rounding  tissues  remain  unchanged!-'  And  how  is  it,  also,  that 
the  removal  of  a  large  segment  of  the  hypertro[)hie(l  tonsil  will,  in 
most  cases,  effectually  check  the  recurrence  of  (piiusy? 

Pathology. — Although  acute  tonsillitis,  as  a  rule,  results  in  s>ip- 
puration,  yet  in  some  instances  it  extends  no  farther  than  acute  in- 
flammation, becoming  red  and  shiny:   according  to  Leland.  the  jiaren- 


m 


24(1 


DISKASKS   OF    rilK    I'lIAIlYNX. 


cliynuitous  variety,  'riicro  iiiiiy  he  inliltratioii  witli  incroased  cell  and 
lyjiiplioid  dcvc'lo]iin('iit,  tojri'tlicr  witli  tlu;  proscneo  of  pathnlojiical 
goriiis  within  the  crypts  of  the  tonsil.  Stroplooocous  jjynLronc.s  and 
|)nciunoco('ci  may  he  prosoiit;  hut  i^o  h)nji  as  they  arc  ail  on  the  sur- 
face or  witliin  the  crypt.s  oidy,  and  not  uitliin  tin;  drcpcr  tonsillar 
or  areolar  tissues,  ]»h]e<;nionoiis  aliscess  docs  not  occur.  In  a  lai'tjc 
proportion  (tf  cases,  however,  the  infectious  ])rocoss  doi's  not  stop  here. 
The  IncnnjG  of  the  tonsils  niny  heconie  blocked.  l*atho,i,'enic  f^erni.s 
nuiy  already  have  found  an  ci)ti'anc(\  and.  the  eiypls  licin;,'  (dosed. 
exposure  to  the  surface  cold  uiny  produce  hypei'a'Uiia  of  a  rhcuniatie 
throat,  iind  inllainniatory  action  he  developed  in  all  its  intensity.  In 
a  rheumatic  diathesis  the  peritonsillar  tissue,  particularly  when  pressed 
by  a  liard,  liypcrtropl\i(Ml  tonsil,  will  he  prone  to  intlammatory  action, 
and  havijig  commenced  may  soon  spi'cail  In  the  suiTonndim:  tis-ue 
and  the  tonsil  itsidf.  I'us-corpuselcs  are  formed,  a  phleuiiKuious 
abscess  results,  and  streptococci  pyo<ren(\s  may  be  found  in  larire  num- 
bers.   Sonu'tinies  pneumococci  and  stapliylocoeci  will  also  be  present. 

The  site  of  the  abscess  varies  greatly,  sometimes  it  is  in  front 
of  the  juncture  of  the  anterior  and  posterior  pillars.  .\(  others  deeply 
seated  behind  the  lower  part  of  the  anterior  f(dd,  pressing  the  tonsil 
inward  almost  to  the  opposite  wall  of  the  pharynx.  .Again,  it  may  be 
at  the  ])osterior  side  of  the  tonsil,  deeply  engaging  the  soft  palate 
and  uvula  in  inllammatory  infiltration,  while  not  infre(|nently  the 
whole  body  of  the  tonsil  itself  may  be  the  subject  of  phlegmonous 
enlargement. 

When  the  pus  forms,  the  soft  character  of  the  surrounding  tis- 
sues do  not  tend  to  limitation.  Fortunately  it  spreads  e(|ually  in  all 
directions,  and,  there  being  no  dense  membrane  between  it  and  the 
surface,  spontaneous  evacuation  usually  soon  occurs.  When  the  sup- 
puration is  decjdy  seated,  behind  a  dense  hyperplastic  tonsil,  ])rogress 
toward  the  mucous  surface  is  more  tardy  and  the  pus  may  burrow 
extensively  into  the  surrounding  tissues.  Velpeau  reports  a  case  in 
which  the  pus  made  its  way  into  the  cellular  tissues  of  the  neck  as 
low  down  as  tlie  clavicle.  L*cid  reports  another  in  which  the  ])ns 
burrowed  along  the  course  of  the  great  vessels  into  the  ]deural  cavity, 
resulting  in  death  from  empyema. 

Tn  some  cases  the  tonsillitis  is  confined  cntirtdy  fo  the  tonsil,  and 
is  deeply  ulcerative  in  character.  Lake  reports  a  case  of  this  nature. 
The  ulcer  was  as  large  as  a  shilling  and  covered  with  a  tenacious 
gray  slough,    lie  removed  the  tonsil  and  in  five  days  the  young  man 


ond-i'ii  \i;VN\.     griNsY.  V  1 1 

\Vll!i  Well.      'I'llf   llllr|n.-(  i)|i('    IcVcillrd   lill';;*'   lllil.-.-L'»  ol'   lirildctl    hiliilli    oil 

tlio  advaiiei'd  nl'^a  ol'  llio  tfluiigli. 

J';du'>  H'poits  tiircc  cfiscs  ol'  lU'uU'  tuiif:illiti>  in  wliii'li  the  tnii- 
fil.s  tilt  iii.-t'l\t's  wcro  tlic  .«(':il  of  till'  dist'iisc,  huiiig  in  ciU'li  liisc  rrd 
and  swollen.  On  nii('rosco|iii;d  cxiiininalioii  of  the  lilood-M  rum  ;i 
|uire  cultnrt'  of  {'"ricdliindcr's  liacilliis  was  found  in  lacli,  in  one  of 
tlimi  lii'inu  !is.-ociatrd  wilh  sta|iiiyl()c()ccns  auicii*. 

Etiology.-  'i'lii'  ]»ciiod  of  life  duiiiiL;-  uiiicli  this  iliscasc  is  most 
|)n'vali'nt  is  hului'un  llio  ages  of  lo  and  10  }'tars,  tlu'  largci'  luuidxT 
bi'ing  near  thu  ixMilio  uH  that  period.  Slill,  s(jiiic  oeciii'  even  in  ehild- 
hood,  while  a  very  few  aii'  reported  among  the  liflies  and  sixtie.s. 
The  rheuiiiatie  diathesis  is  a  predisposing  cause,  and  in  many  casis 
aoiite  rheiiinatism  of  the  joints  is  a  pri'lude  to  rheumatic  tonsillitis, 
while  in  othef  instances  the  tiuinsy  precedes  liie  gem'ral  rheunuiti.-tn. 
Siu'cessive  atl  icks  td'  tonsillitis  lend  to  prodtiee  liyperlrophy  (d'  the 
tonsil,  while  the  increasing  hypertrophy  jironioles  .susceptihility  to 
intlaniniatoiy  action.  The  disease  occurs  more  frequently  aiiumg 
males  tlian  ft'.males,  owing  to  the  greater  exposure  as  well  as  climatic 
])rivatioiis  to  which  men  are  suhjecl.  There  is  also  in  scuno  cases  a 
marked  hereditary  teiulency.  This  ocurs  chielly  in  strumous  eases, 
liyperlrophied  tonsils  being  a  prominent  feature  of  development.  One 
fact  is  readily  observed,  that  ijuinsy  rarely  occurs  when  the  tonsils  are 
of  normal  size. 

'J'lie  usual  exciting  ean-e  is  sudden  and  unei[ual  exposure  of  the 
body  to  cold.  The  chilling  >  f  the  surface,  and  the  consequent  con- 
gestion of  any  weak  internal  organ,  will  in  many  instances  tesid  to 
the  development  id'  the  disease.  'I'liere  is  aimther  point,  whieli  1  do 
not  reineinbi'r  lo  have  seen  referred  to.  but  which  I  have  ol)~erved 
in  practice,  and  that  is  that  the  majority  of  eases  of  quinsy  occur  in 
mouth-l.M'cathers.  The  constant  oral  respiration  exposes  the  throat 
to  a  variety  of  changes,  both  of  leinperalurc  and  purity  of  air,  wliicli 
the  normal   bi'i'ather  escapes. 

Symptomatology, — The  dejnTssing  cll'eet  whicli  tliis  disease  lias 
upon  the  nervous  .•system  is  indicated  by  the  feeling  of  weariness  ac- 
companied by  chilliness  and  exhaustion,  with  which  it  is  often  ush- 
ered in.  For  the  first  day  or  two  general  febrile  action  takes  place, 
risinir  to  lo'i'"  or  lo.'5°,  in  some  cases  even  higher. 

These  symptoms  are  accompanied  by  ])ain  in  the  affected  tonsil, 
swelling  soon  takes  place,  and  in  two  or  three  days  it  may  become 
so  great  as  to  materially  interfere  with  deslntition.    When  the  disease 


ij'i 

It 


'  V 

Ifl. 


'f   j! 


248 


1)1si;asi:s  oi-     'in-;  I'Hakvnx. 


is  pcritonsilliir  tlie  ti>>\ic<  1)ltoiiu'  voiy  l)ra\vny  and  jiainfiil,  the 
muscles  swollen,  and  the  iiidvenients  ol'  the  inferior  maxilhi  are  ma- 
terially interJ'ered  with.  The  ell'orts  to  swallow  even  Jluids  are  some- 
times almost  unavailing,  and,  ouiiiL  lo  the  imperfect  action  of  the 
swollen  jialate,  they  may  escapi'  thi'(  ii.iili  the  nose  mi  the  ell'ort  of 
swallowiii::-.  'I'iie  voice  becomes  mu!lle(i  and  indi-tinct,  and  sleep  al- 
most im])os;-ible.  At  first  the  pain  i-  ^harp  and  lancinating.  Later 
on  swelling  occ^irs,  and  the  pain  I.ecMines  nf  an  oppressive,  aching 
character.  As  the  swelliuL:'  in  the  ihi'oai  lieconio  greater,  s;diva 
drihhU's  from  llw  moiuh  and  llie  jaw>  heconie  almost  immnvahli.'. 
'J'he  temperature  goes  i|ov\ii.  ihe  hoily  may  he  hathiMl  in  c(jld  swci.ts, 
and  even  respiration  may  he  si('rloi'(nis  a^  impcdeil.  I.itth;  or  no 
nourishment  can  he  laki'n.  and  llu'  recumhcni  jtosturc  heconu's  almost 
impopsihle.  This  cniulition  may  continue  sevei'al  days  without  relief 
is  given  liy  surgical  :  '"ans.  i-'inally  tlie  pu-^,  aiming  at  some  point 
within  the  ]iliai'ynx  or  hack  part  of  the  mouth,  gradually  softens  the 
surface  meml)i'aiu';  the  mucMisa  gives  way,  ami,  the  pus  lieing  dis- 
charged freely,  the  jiatient  obtains  imnu'diate  relief. 

When  the  disease  attacks  both  tonsils,  it  is  rarely  exactly  at  the 
same  tinu',  hut  in  (piick  succcssiim.  the  one  being  invailcd  within 
two  or  tliree  days  of  the  other.  They  then  run  their  course  almost 
together,  the  main  dill'cri'uce  between  single  aiul  double  tonsillitis 
being  iti  severity  of  .-symptoms. 

Diagnosis. — The  acuieness  id'  the  iidlammatiuu.  with  its  rapid 
development,  ai.d  high  fever,  should  distinguish  it  in  all  cases  from 
syphilis,  tuberculosis,  (U'  maligTuint  disease.  With  reference  to  other 
acute  afTections,  the  characteristic  symptoms  o"  quinsy  should  render 
the  diagnosis  plain.  Th(>  sudden  onset  of  high  fever,  accompanied  by 
sharp  unilateral  jiain  in  the  tonsil,  bright  redness  and  swelling  in 
one  side  of  the  throat,  the  ditllculty  in  swal  owing,  the  immobility  of 
the  jaws,  the  dilTIculty  of  bending  the  neck,  aiul  Ihe  peculiar  dis- 
tressing look  of  the  face  point  to  this  disease  in  contradistinction  to 
all  others.  When  the  disease  is  double,  th.e  intensity  of  Ihe  symptoms 
shotdd  retider  the  diagnosis  more  certain.  l'r(un  ]ihleguinnous  abscess 
of  the  post-pharynx  it  must  be  distinguished  by  the  position  of  the 
enlargenuuit.  and  the  greater  impediment  to  respiration  which  the 
disease  induces.  Talpation  is  always  a  nuitorial  aid  in  diagnosis.  In 
the  early  stages  the  brawny  feeling  of  the  abscess,  wherever  located, 
may  he  outlined,  and,  as  the  suppuration  advances,  the  point  of  soften- 
ing can  be  readily  discovered. 


OKO-1'llAUVXX.       QIINSV. 


2\\) 


lu  tlu'  coniineiiceniont  Uicre  is  a  possibility  of  confounding  this 
disease  with  (liplitlieria  and  acntc  lacunar  tonsillitis,  hut  attentive 
ol)servati()n  should  remove  all  ditliculty.  Tlio  onset  is  more  sthenic 
than  ill  diplithiTiii.  hut  there  is  less  eiilarti'einent  df  the  viands,  no 
albuminuria,  no  development  of  false  nieinlirane.  As  to  lacunar  ton- 
sillitis, the  jiresence  of  tonsillar  exudalioii,  unaccompanied  by  much 
eidar^'ement  or  by  deep-seateil  pain<.  should  dislini,niish  it  at  onie  from 
the  more  scritur;  malady  of  tonsillar  abscess. 

Prognosis, — Acute,  painful,  and  excei'dinuly  distressinir,  as  the 
disease  always  is,  it  very  rare'*'  |ud\rs  fatal  per  sc.  When  it  does  do  so, 
it  occurs  either  from  (cdeina  of  the  air-passages  or  extension  cd'  the 
abscess  into  the  surrounding  tissues.  It  is  a  self-limited  disease,  and 
runs  its  course  in  from  oiuj  to  two  weeks.  Afler  free  evacuation  of 
the  pus-cavity,  wbellier  by  necrosis  of  the  surl'ace-tissiie  or  by  surgical 
operation,  recovery  is  ii-iuilly  very  rapid. 

The  possilhlity  and  e\en  prolndiility  of  the  recurrence  of  the 
disease  should  always  be  borne  in  niind. 

Treatment. —  CnforfuiiaJcly  in  this,  as  in  many  other  alTcctions, 
the  patient,  as  a  rule,  does  not  seek  treatment  until  the  disease  is  well 
established;  and  by  that  time  it  is  too  late  to  aliort  it.  Prompt  treat- 
ment on  the  'irst  appearance  of  the  throat  .-symptoms  would  in  many 
instances  check  its  progress.  For  this  object  a  saline  cathartic,  such 
as  sul])hate  of  magnesia  or  Eoeludle  salts,  may  be  given,  followed  at 
once  by  a  dose  of  \/._,  to  1  gramme  of  (piinine.  I'rompt  treatment 
of  the  tliroat,  also,  should  be  attended  to.  First  wash  it  horoughly 
with  a  sjiray  of  DobelPs  soliiiiiui.  Then  api)ly  a  10-pcr-cent.  solu- 
tion of  cocaine  freely  to  the  affected  tonsil,  and  follow  this  ity  brush- 
ing it  with  a  lO-pei'-cent.  solution  of  nitrate  of  silver.  The  cocaine 
tem])orarily  drives  away  the  blood  frcmi  the  congested  tissues,  while 
the  cathartic  is  attempting  to  prove  its  elliciency.  The  astringent 
and  autiscjitie  eflVct  of  the  silver  will  remove  a  good  deal  of  the  super- 
ficial iri'ifation,  as  well  as  destroy  the  surface  and  lacunar  bacteria, 


th 


lus  ])roduciuu'  a  trene 


ral  sedative  elfect  uiion  the  intlamcd  gland. 


Other  astriuLTciits- — such  as  solutions  of  siiliihatt'  of  coi 


pe 


r,  alum. 


or  tannic  acid — might  he  tried,  but  they  lack  the  elTectivencss  of  llie 
sil'  er  nitrate. 

If  the  tonsillitis  is  of  rheumatic  origin,  full  doses  of  salicylates 
should  he  given. 

Failing  the  abortive  treatment,  other  measures  will  be  required. 
As  the  disease  advances,  it  becomes  very  diHicult  to  open  the  month; 


p 


250 


DISEASES    OF    THE    I'HARYNX. 


and,  while  examinations  may  \)g  necessary,  in  order  to  keep  cognizant 
of  the  location  and  ])rogresa  of  the  disease,  freqnent  digital  exami- 
Jiations  are  inadvisable.  The  touch  of  the  linger  in  the  early  Ijrawny 
(!ondition  may  help  to  clear  up  the  diagnosis;  but  even  tlien  it  is 
scarcely  necessary.  Subsequent  to  that,  the  touch  of  the  (Mjiton- 
holder  with  its  thin,  tirni  stem  and  little  pledget  of  cotton-wool  on 
the  end,  aided  by  reflected  light,  should  be  sullicient  to  indicate  the 
condition  of  the  parts. 

When  pointing  is  indicated,  from  the  grayish  color  and  softened 
condition  of  any  spot,  it  is  best  to  open  the  abscess  freely  at  once 
and  liberate  the  contained  pus.  The  question  often  arises:  Should 
we  lance  the  inllamed  tissues  earlier,  or  before  we  are  absolutely  sure 
of  the  presence  of  purulent  matter?  In  many  instances  I  believe  we 
should.  1  have  seen  instances  where  a  dee|)  incision  into  the  tonsil 
itself,  producing  free  venous  haemorrhage,  without  the  nutlet  of  pus 
at  all,  has  been  followed  at  once  liy  relief  of  the  most  urgent  sym[)- 
toms  and  gradually  recession  of  the  disease.  Another  instance  I  can 
well  rememljer,  in  the  case  of  a  rheumatic  patient,  in  which  the 
])harynx  was  almost  filled  with  an  intensely-painful  riglit-sided  phleg- 
mon. The  teeth  could  not  be  opened  more  than  1ml f  an  inch;  but, 
inserting  a  tongue-depressor,  a  deep  and  long  incision  was  made 
])arallel  with  the  edge  of  the  anterior  pillar.  Bleeding  was  very  free, 
but  there  was  no  pus.  IJelief  from  the  severe  tension  was  marked, 
and  twelve  hours  later  pus  commenced  to  flow  from  the  wound. 

While  incisions  to  give  relief  re(piire  to  bo  free,  tlie  ])roximiIy 
of  important  vessels  should  always  be  borne  in  mind.  The  intonu'l 
carotid  artery  is  in  near  proximity  to  the  posterior  and  external 
border  of  tlie  tonsil,  and  if  wounded  death  might  result  before  the 
vessel  could  be  cut  down  upon  ami  ti('(l.  As  a  rule,  however,  it  is 
better  not  to  lance  until  we  are  morally  certain  of  tlie  formation  of 
pus;  and,  without  the  o]ierator  is  perfectly  sure  of  his  bearings,  this 
should  be  tlu-  law  in  all  cases.  Sometimes  the  jjus-cavity  is  not  a 
single  sac,  and  several  ojienings  nu\y  require  to  be  made  before  all 
the  pus  can  be  discharged. 

Frequent  gargling  of  the  throat  with  hot  waler,  before  and  after 
operation,  will  usually  have  a  grateful  elTect  upon  the  patient;  and 
the  sanu'  may  be  said  of  steaming  the  pharynx  by  means  of  a  rubber 
tube  attached  to  a  kettle  of  hot  water. 

With  regard  to  external  applications,  many  believe  in  hot  poul- 
tices to  the  neck;  while  others  recommend  the  application  of  crushed 


I 


OUO-PirAIiYXX.       ycixsv.  ggj 

ieo  in  the  sa.no  way.     In  my  own  c.xp.ri..,,,-.  a  nn,,,!..  nuahu,!  Ins 
sufi-cod,  g.v,n,  e.,nal  c.nlort  with  l...  ,n.nl,l..     Wann  .pint  of  t 
po^^.no  and  ohve-oil  ,„  „,„,,  ,„,„  ,,„,,  ,,„,,,„„,  ,,„„,^.  ,_^^  /  J 

of    he  tonsds  and  tl.en  a  tlu.k  narrow  lay.r  ol'  .u;,oon:  al.     C 

cot  on  was  appli.nVon,  side  to  side  and   ,a>,.„..d  r;.  ,,,,;,,,; 

mn^    an   a,e      TJus  was  repeated  twice  a  day.  se.unnl  a  .en.at  o 
01  warinth  and  support. 

Dm-in^  the  progress  of  tl.o  disease,  lid,,  and  no„,i.lnn.  diet  will 

'T               lu.deuey  in  r..,-,uTe,Ke.     Tlw  onln.arv  ruh.   reonlatin. 
c^iet,  c.lotlnng,  and  hy.iene  d„u,ld.  of  , ..,  ,.„  ,;,,,„,,„,.     ;[,';; 

^-..however    of. dl,,UH.r.u,., .,vnn.e...^ 

h3porp]as,an    ,lH.,on<dswlneh  .ill  ,..v.„,Uu.  n.nrn  ;',•,!,..     ,,in.v 
islhe  reinnval  of  ll,e  diseased  nl,,,,,!...  ' 


;i 


i!.1) 


CIIAPTKli  Xi.Vl. 


iJJSKAbKS  UF  TllK   L  \  LLA  :    iKlJli.MA;    ELUMiATlOX. 

(Kdema. 

'i'iii>  i>  a  .-iiii|i|i'  scTdiis  cxuiliitidii  ii)tt)  the  ilccjn  r  layt'i'.s  of  the 
Tiiiii'ou.-  iiu'iiiiiiaiii'.  W  lull  .-I'Vt'i'i'  ami  lu'nldiiucil.  liio  (ilircs  of  the 
azygov  uvula'  iiiav  he  iiivuhed,  also  the  soft  ]ialate  an<!  jiillars  of  the 
faiiec's.  Ii  i>  llie  stToiiil  sta--e  of  iiillaiiiinaton'  r.otion  in  the  softeiieil 
ami   iclaxid  ii.-,-iie>. 

Etiology.-- -t  I'Jii'ina  of  the  inula  is  almost  always  of  a  seeoiulavy 
iialur(\  liaviiiii'  its  origin  iii  aciile  or  ehnuiie  inllammaticii  of  souk; 
porlinii  of  the  nose  or  na-o-)ihai'yii\.  Occasionally  it  is  a  rellex 
Iraumatisiii  from  surgical  ofieratioii  upon  the  lurhinaleils  or  faucial 
tonsils.     SonietiiiH's  it  is  idiopathic. 

in  one  patient  I  was  struck  \v  h  the  peculiar  fact  that  on  several 
occa>ions  the  ajiplicalinu  ni  iii-|i(.i'-ccnl.  snlntion  of  cocaine  to  tlie 
nasal  cavity  preparatory  to  operati'iii  was  followed,  in  les-  Ihan  half 
an  luuir.  hy  (edema  of  the  uvula,  which  in  a  ciiu|ile  of  hours  spou- 
tanemisly  siihsided. 

It  may.  in  a  W'W  cases,  he  the  resnit  of  pharyngeal  tuberculosis 
and  nisii  of  general  ana-area. 

Symptomatolog'y.--  A  tickling  sensation  in  the  middle  of  the 
throat,  with  a  feeling  cf  fullness  as  if  from  the  presence  of  a  foreign 
body,  accoinpanicd  by  c(Ui-lant  elVorls  to  clear  the  pharynx  by  hawk- 
ing and  swallowing,  ai'e  the  leading  .-^ympicnus.  I'hysieal  examination 
will  at  onec  reveal  the  ciuidition.  The  jialate  will  be  relaxed  and  the 
nvnia-clongated.  thickiiied.  and  baggy — will  have  hist  its  normal 
]iinl\  hue.  and  assumed  ihal  (d'  a  transparent  bag  of  serum. 

Prognosis.- -When  it  ;iii-es  fi'(uii  traumatism,  the  subsidence  will 
be  spontaneous,  usually  within  a  few  hours.  When  fioni  acute  or 
chronic  disease,  the  swelling  may  not  so  soon  abnl(\  l'"acli  case,  even 
without  treatment,  sluiuld,  in  time,  .>-iib-ide,  unless  it  owes  its  origin 
to  general  dropsical  ttVusion.     \'o  fatal  case  has  lieon  rocorded. 

Treatment. — .\s  a  rule.  tli(>  treatment  for  the  renuival  of  the 
primary  cause  is  all  tluit  will  ho  required.  When  'he  symptom.?  are 
(552) 


OKO-rilAKVXX.       KLONGATIOX    OL'    TIIH    UVfl.A. 


^J3 


very  distrossiiijr,  astringent  gargles  of  tannic  acid,  subacetate  of  lead, 
alum,  ete.,  might  be  used.  In  otiiers  the  .-iirface  of  the  uvula  might 
be  brushed  with  a  solution  of  cocairu''.  and  then  tlie  mucous  mendiranc 
could  be  jiuiu'tui'cd  in  a  niiinbcr  (d'  |ilai-cs  with  the;  |<(iint  of  a  lance, 
to  alliiw  tiiL!  cll'n.~i(iii  to  escape.  Sulisci|Uciitly  the  throat  coubl  be 
.-tt-anicd,  or  a.-iringciit  gargles  usi-d. 


iM.ONiiAridN  oi'   I  in:   I  vri.\. 

Tliis  i^  ri'djiiriitlv  assuciiitcd  wiili  h v|n'il mpliv  oi'  ihi'  (irgaii. 
Xormally  the  ii\ida  -hmild  h;iii^r  dnu  ii  fr.'i'ly  within  ihc  taiircs.  uilii- 
out  touching  the  t  mguc,  and  (d'  a  hiigth  vai'ving  from  eight  [n  iwclvi; 
milliiiu'lrcs.  The  muc(ui~  ini'inhi'mic  >hniild  |ii  (•h)S('ly  to  the  niii>clc 
hcncalh,  and  the  surface  shmdd  lie  liini  iiiiil  t>\'  a  clear,  piid;  enh)i'. 

When  elongation  takes  |ilaee.  the  leiiulii  may  he  even  ihree  centi- 
metres or  more,  and  uider-s  ihi'  iiicrca.-e  in  length  aiises  nui'ely  rmm 
(I'dematuus  llii(d>;cning  o\'  the  mncMus  niendirane  there  is  u-ually 
present  hypertrophy  likewise. 

Pathology. —  As  a  I'ulc,  the  eomlitidn  nf  clircnic  irrilatinii  which 
eventuates  in  eloiigatiitn  (•imlines  ii-elf  in  piddiieing  hy|ier|i|;isia  id" 
the  nuiciuis  inendii-ane.  the  while  lihi'niis  and  clastic  tissue  (d'  the 
muscle  remaiiung  unaU'ectcd.  ConseiiiU'iitly  ihe  .  hmgatitut  is  purely 
beh)w  the  azygn.-.  Still,  c.ises  iKcur  in  which  the  whoh'  organ  is  of 
abnormal  thickne.-s  as  well  as  length;  nf  a  I'eil,  deeply-eongested 
coloi';  and  in  which  even  the  free  applicaiion  of  ln-|H'r-t'ent.  solution 
of  cocaine  will  produce  very  liiniied  ,-hrinkage.  In  liicso  cases  the 
azygos  mnselo  extends  down  deculeijly  below  ihi'  centimetredinc.  and, 
the  whole  organ  has  the  a[i]iearani'e  of  a  lai'ge  tleshy  mass,  d'hc 
permanent  congestion  seems  to  result  in  grannlar  hyperplasia  of  the 
lihrousdissuc  elements,  situated  below  the  true  mucosa. 

Etiology. — l-'longation  of  the  uvnla  is  so  fi'eiiucnl  an  attendant 
upon  chronic  nasa.1  and  naso-pliaryngeal  disease  that  it  wmdd  seem,  in 
the  majority  of  ca-es,  to  owe  its  origi?!  to  their  prcst'ucc.  The  jiei- 
p(dnnl  movement-  of  the  palate  to  clr.ar  the  itaso-pharynv  keep  it  in 
a  stale  of  constant  ii-rilalion.  resulting  successively  in  relavMioii. 
I'lotigation.  and  hypertropliy.  A  weakened  conditimi  o\'  the  >  -'.ni 
oi-  l()ss  (d'  mnscnlar  tone  may  accentuale  the  ironbic,  allowing;-  a  I'e- 
laxcd  palate  to  diop  I  he  nvnla  upon  the  toiie-ne.  'I'he  conslaid  elfort 
of  the  patient  to  dislodge  lU'  swallow  th(>  seeming  foreign  body  has 
the  cfToct  of  keeping  the  uvula  in  a  congested  and  irritable  condition. 

In  some  instances  the  chnigation  is  congenital.     In  these  cases, 


t^ 


')i 


J.^51 


I)Isi;asi:s  ok   jiik   i-iiakynx. 


Aviici'c  there  i-  iiii  iiiiso-|ili;nTii,i;ciil  ii'ritiitinn  to  ii^'u'i'iivate  the  iroublo, 
tluTL'  is  lillle  likeliliiHid  (if  livperlnipliie  (level(i|iiiieiit.  llie  siiiijilo 
('U)ll,t:;lleii,   leilellialnlis    ll\lll;l    lieillt:'   il  1 1    tlllil    i>    likely    ti)    oeelir. 

Symptomatology. The    -yiniildin,-    emue    (ni    .-n    .i;r,-i(lu,illy    nml 

|iiiiiik'-.-ly  ihiil  ejiiiii^iiiidii  I  re.|iieiitly  i,~  imi  I'eedi^iii/eil  iiiijil  invosti- 
Llillinll  I'm'  Mime  iither  (li-eii~e  reVejll.-  ils  |ire.-eliee.  'I'lie  .-y lll|ii(iIIIS  11 11' 
ihiisL'  (if  iiiiiin.'iiy   ihniiii    iri'iliil  inn   -iiiiiliii'  in  tli(i>e  nf  (edema   (if  tlio 

ll\ll]ll.    hill     dl'    millnl'    (IcLlli'e. 

I  )e,iiliit  il  idii  is  mil  much  iiilerrere(l  wiih.  hut  iihdiiatjdn.  wlieii 
ihei'e  is  hy|ieiMi'd|iliy  a-  well  a>  ehm.i^at  i<iii,  i.-  IVei|iieiitly  all'eeteil. 
This  is  partieiilailv  ihe  ease  with  [iiihn_c_sjj(/ajitxs_  iiiHl  siii^'i;.<.  Id 
these  it_jnv(s_the  voice  a  2!J"lJi':iJ..  thidaly  eharaetei',  as  if  tlio  iiiidiia- 
tidii  issued  lioiii  the  jihaiviix  witluiia  the  clear  control  of  the  iiuisc-les 
id^jjhe^ljingiie  and   iiioiitl|. 

'J'he  eoiitih  in'odiieed  liy  ehinualioii  df  the  ii\iila  is  of  an  ii'i'itahle, 
nervous  eharaetei'  and  iinaeedm|ianied  hy  e.\|ieelo!'at  ion.  sa\'e  that 
which  can  he  hawked  up  from  an  ordinarily  catai'rhal  |iha!'yii.v. 
When  the  iivnla  is  very  Ihiil:'.  iIk.'  >iipine  position  will  cause  ii  to  lie 
dii  the  po>t-pliaryn.uial  wall.  While  llie  uprisjhl  po>ilioii.  if  the 
larynx  is  silualed  hiuh  in  ihe  ihroat,  aill  make  ii  loiieli  tin.'  e|ii- 
ulottis,  in  t'ilher  ca.-e  prodiieini;'  lemporary  irrilalioii  and  cdiiLih. 
A.-tlima  is  recorded  as  one  nf  ii-  relle\  results. 

Diagnosis. --'I'll i<  can  only  he  a  mailer  of  simple  examiiialioii. 
Wliellier  thick  or  thin,  if  Ioiil:  and  pendulous,  and  accomjiaiiied  hv 
ihroai  catarrh  and  iicivou-  cnuiih.  ii  may  he  cdiieliided  that  the  con- 
dition of  t  his  oi'uan  is  aluiormal. 

Prognosis.- -'I'o  life  it  invokes  no  (lauLrer.  To  ^cncfal  health 
\ci'y   lillle.     'i'o  the  .-pcakcr  or  sin_i;i'r  llui  presence  of  the  elonixalion 

i-  not  a  [S I   nineii.  as.  without  operation,  the  dillienltv  i-  likelv  to 

he  permaiiciil.  lleiice  ill  thest'  casi's,  and  in  all  where  il  i-  accom- 
p;inied  hy  llii'oal  irritation,  the  proLinii>is  sliould  |)oinl  lo  a  Mat  ion 
of  a  jiortion  df  the  otl'endin,i:"  nieinlier. 

Treatment.  -In  mild  ea.-es  dev(ud  of  aiinoyiiiL;  .-vmptiun-  the  use 
of  astrinu-enl  ,i;ari;ie<  may  he  df  lieiicllt.  j'erhap.-  the  lie~i  of  these 
\Miiild  he  Lilyecro-iannic  nr  sulphate  of  irdii.  Tdiichiiii:  Mie  end  df 
the  nviila  al-o  wiili  a  ln-|i(.|--ccnt.  .-dluiioii  id'  nilrale  df  -iUer  miiiht 
he    of   service.       When    the    clom-'atioll    i-    produced    entirelv    hv    livper- 

tropliy  df  ihe  miieii-a.  hru-hini;  \miIi  liiicinre  df  indine  niav  he 
iltlended    h\    L'ond    iv-iill-. 

In   iiid-l    (ii-e-.  Iid\\e\er.  a   -li:jht   opeialion   will   he   found   neees- 


;  I 


n|{()-|-|l  \1!VN.\.       Kl.ONCA  THIN    (tK     llli;    I   \l   l.\.  V.).) 

sary,  tlu'  ri'diiiHlaiil  [un'lioii  nl'  ilic  uvula  n'(iuiriii^'  to  \)v  rciiinvril. 
In  (loiiiff  lliis  there  i.<  always  daiiffor  of  cuttiu''  olT  too  larw  a  iiurlidii. 
If  we  (k'sire  to  (sfaMisli  a  siiii|ik!  rule  thai  iniulit  ,u(iv<'rii  all  cases 
ill  uhicli  operations  was  alisoliitoly  nMiuire(|,  i,  iiiiulit  he  iliis:  -V('''o' 
Id  cut  off  liioir   ',l:<in  mn'-lKtlf  j'roDi  llic  h'lnjlii  nf  llir  iiniln. 

As  in(1ieat<"l,  IroMi  whal  lias  already  heeii  ,-aiil,  the  excision 
sliDiihl  only  he  ;lial  ol  the  hy  |iert  rophieil  niiH'oiis  iiieiiihiaiie  al  the 
eiul  nf  ilie  u\iila.  in  ea-''-  una!  leiideil   hy  niii-eiilai'  hyiieil  rnphy. 

'There  ari'  -eveiai  nietliod-  ]i\  wliieh  ihe  lillle  operation  ean  lie 
perfiiriiied,   ea(di    iiiethnd    re(|iiiriiiLi'   dilTereiit    in.-l  riiuieiii -.      .Maeken_- 

zie",-    llVlllotollie    llliiihl    lie   luellliolled.   eiiH.-lrihli'il    nil    llu'    principle   of 

the  faticia!  toii.-illninnii'.  Ilo-woriirs  >erraieil  ^eissln■s  is  al-o  prai-ed 
iis  a   u'ood   in-l  ninieut.   ina>iiiiieh   a-   the  .-errateil   idadi-   prevent   any 

possihiliiy   of   -lippin_t;   (I'i.i:'.    'i-M-     Jlc IjIoIb's  galvaiioeaiiterv-Liiiillo- 

tiiie   is  an   iiiLieiiioii-  in-trunieiif.   preventiiiL;'  any  lueinnnham'  al    the 


I'l-x.  Til.      I 'villa  seissiiis.      f.Vflrr    I'losw  ml  li.) 

liine  of  operaliiin.  Kyle  uses  a  >liaip  hi-lmiry.  eiiltiiiL:-  out  a  wediic- 
sliaped  pi<'ee  from  the  einl  (d'  the  iiiiila  and  thii>  avoidin;^'  a  eliih- 
sliaped  >tiiiiip. 

^^y  own  pV(d'erenee  lies  with  the  lollii'  and  eur\cil  sei>sor.~  to- 
.Uelher   with    lollii-.    inolise-toiit  lied    foicep^. 

Ill  opcratiii"'  1  invariahly  secure  the  pali<'iit'-  a^-i-laiiec.  (I  have 
only  seen  one  ease  in  childhood,  and  in  this  ihe  iisula  was  removed 
under  'dilorofiprin. )  A  In-prr-cenf .  -idutinu  id'  eoeaiiie  i-  lirst,  applied 
on  a  plcd^ict.  of  eonon  to  ilir  n\iila.  1'lie  palieiM  ili.'ii  hold-  thr 
toiiLiiie  down  with  a  toiiL:Ue-depre>sor.  With  the  left  hand  llm  oper- 
ator seizes  the  inida  Hear  llie  ivxtremilv  with  the  foi'ccp-.  and  draw- 
it  p'ciitly  forward  without  piiilini;'  it  on  the  stretfdi:  and  with  tlie 
vi.Lilit  applies  the  Mi-.-nrs,  leaniii'^'  upward  ,ind  haekwaid.  so  a-  to  cut 
the  u\ula  with  an  aeule  aiiuh'  to  the  front.  Ily  ihi<  iiieaiH  the  heal- 
iiiii'  is  mostly  nn  the  posterior  surface,  the  anterior  niueiMi-  meinhrane 
lieiiin-  hd't   almost  entire  tl''ii:.  SO). 


;J:i  : 


i: 


2')(\ 


])isi:.\si:s  ov  nii:  rnAifVNX. 


I'  I 


■H 


Xo  furtlic'  Irciitniciil  is  nM|iiirc(l  except  to  iiisist  upon  light ^soft 
^^t^)f  ti  CHHiiMeinpi'RUure  lur  a  day  orjwu.  No  coiidiiiionls  or  hot 
iluids  or  irritants  of  any  kind  sliould  he  tai\cn  duiing  that  period, 
on  accdunt  dl'  the  anilc  pain  they  might   proihicc. 

Sevt-rc  hiiMnnii'lingc  al'tfi'  iivnhitdiny  i.-  t\c(M'din,::ly  rare.  One  or 
two  deaths  have  iie<'ii  icported  i'ollowiiig  the  operation.  Imi  it  is 
(h)ubtl'ul  if  Ihi'  dcatli  really  oceiirred  as  a  residt.  A  i'vw  eases  of 
severe  hannorrhage  after  the  operation,  some  of  them  dillieult  to  con- 
trol, have  also  l)een  re(iirdc(L  In  a  iiumher  of  these  many  lionrs 
elapsed  liefni'e  the  hiecdiiig  eniild  \h'  stopjied;    and  in   lialf  of  ihem 


,^^:« 


I'iti.  SO.      I'".\tisi()ii  of  iiMilii.      lAftiT  liosw ortli.) 


the  whole  organ  had  been  removed.  If  the  uvula  itself  was  liyper- 
tro))hied  as  well  as  elongated,  and  the  large  fleshy  mass  was  e.\eised 
entirely  on  a  lin(>  with  the  arches  of  the  soft  ])alate,  one  would  not 
wonder  at  lueniorrhage  l)eing  severe.  If.  on  the  other  hand,  it  was 
accepted  as  a  fixed  prinei])le  never  to  remove  more  than  one-half  the 
length  of  the  organ,  the  ha-mni'i-hage  should  always  he  easily  con- 
trollah](\  I  never  saw  a  ease  wliich  hied  severely,  and  invariably  what 
little  bleeding  did  occur  was  over  in  a  few  minutes. 

If  cocaine  has  been  freely  applied  before  operating,  there  will 
rarely  be  any  bleeding  ai   all  for  several  seconds  after  the  piece  is 


OUO-l'IIARYNX.       KLONOATIOX    Ol-    THE    I  VLM.A. 


ft 


Miipped  oir,  uwiii-  tn  ih-  hIn.Ml   beiii-  driven  out   hv  the  astriiinvnt 
netion  of  the  cocaine;   then  .-li-ht  Llce(lin;L,'  only  will  occur. 

I  have  not  .^cen  a  case  recorded  of  return  of  abnormal  growth  of 
llie  uvula  after  it  had  l,een  once  e.xci.^ed.  Sonic  vars  auojiowever, 
a  clergyman,  aged  oK,  came  to  me  for  treatment".  J  found  that  he 
had  Jiasal  j.olyjiu.s  relaxed  palate,  and  a  very  long  uvula,  the  central 
muscular  portion  extending  almost  to  the  end  of  the  organ.  He  in- 
formed me  that  a  ihrr.at  si,eciali.st  had  performed  uvulotoniy  several 
years  before,  luit  that  it  had  grown  again  and  he  desired  to  have  it 
removed.  This  time  J  reduced  it  to  the  length  of  ah-mt  one  centi- 
metre.    Jt  Jia.»  given  no  further  trouble. 

Occasionally  we  meet  with  c-a.^^es  of  congenital  bifurcation  of  the 
uvula.  One  branch  is  usually  smaller  than  the  other  and  planted  to 
one  side.  If  no  symptoms  arise  as  a  cnnse^nienee,  tliev  shnuld  n.,t  be 
interfered  with.  Sometimes  for  aesthetic  purposes  tiie  smaller  may 
bo  removed.  Wben  tlie  bifurcation  is  even,  extendinir  into  the  palate 
the  edges  should  be  pared  and  the  cleft  closed  hv  fine  sutiuvs 


:ii 


'•ill 


rilAl'TKi:   WMl. 


i!i"i  i;(iiMiAi;\  NcKAi.  .\r.s(  Ks> 


'riii>  ilJM'ii.-c  n'sniiMr-  imi-illai'  iili.-(;fss,  fXccpi    ili;ii    in.-i 


ClKI       Ml 


I  .:/: 


oc(.'iirrin,L;'  iii  llic  tdii.-illiir  I'c^inii  n.  Ii;is  its  oriLiiii  m  ilii'  i>'i<t-))hiir_\  ii- 
gciil  Willi.  (.)irH('  ]i(issiMy  ;iL:-L:i'ii\ak'il  ciisc.-;  ol'  [)crit(iii>illar  iilis(;c>.< 
niiiilit  cMcimI  liy  >iiliimic(iiis  iiijilti'aiinii  intn  tin;  iIccimt  |iliarynui'Ml 
liji.--ii('S  and  i'('>ult  ill  ('MciisivL'  jm^-.-ac  rnniiatKui. 

Pathology. — '\'hv  patliolno-icaj  loiiiiitinii  of  it'i!'n|i|iarviiiiral  ali- 
scoj-s  oci-iiniiiL;'  in  chilillHHMl  ililVci-  Irniii  that  nrciii'rini;'  in  inatiii'i' 
year.-.  Jn  early  lil'c  tlu'  lyin|iliatii'  ti.-.-ucs  arc  in  a  >tatc  nl'  active 
(Icvclopjncnt,  ami  in  tlicir  iniiiuiture  condition  arc  niofc  prone  to  di-- 
('a?c,  Mliorcas,  wlicn  maturity  i.s  reached,  thi.-;  development  has  lieeii 
completed :  permanent  ^lirinka.iie  ha.-  already  coniincneed.  and  there 
i.s  little  tendency  to  .-nppnrative  action  in  them.  In  adult  life  it  is 
the  ei'Unlar  lis.-iics  rather  than  the  lymphatic  that  arc  lialilc  to  in- 
llaininatory  action:  Imt  there  i-  jtrohahly  no  irreater  tendency  to 
al)Sce.-.--devclop!nent  at  thi>  ]ici'io(l  in  the  throat  than  in  other  regions 
of  the   liody. 

The  development  of  alisce,-s  in  c> 'hilar  ti.-snc  i.-  ii^nally  rapid; 
and.  just  as  t|ninsy  will  run  it-  coiir,-c  in  a  vci'y  few  days.  >o  will 
i-ctropliai'ynj^'eal  ahseos.s  in  the  ailiilt  re.-iilt  in  pus-formation  ami  ex- 
tension into  the  snrroundini:-  tissues  in  a  .-imilar  leiiL'^th  of  time. 

in  childhood,  howevi-r.  the  sni)puration  takes  jdace  in  striimou.s 
lymphatic  glands  which  have  ]iri'vionsly  heen  swollen,  and  the  de- 
vcdopnient  of  \\\c  disease  is  a  slow  and  tedious  ]»roc'oss. 

Etiology. — As  in  the  |iatli(dogy.  so  in  llu^  etiolocry.  the  disease 
diU'ers  accdi'diim^  to  the  period  nf  life  in  which  it  occurs.  In  childhood 
the  presence  (d'  the  lymphatic  diathesis  renders  (he  tissues  of  tlu'  post- 
idiarynx  more  ready  to  take  nii  -iippurative  actimi.  The  con-ei|iicnce 
is  that  diirin.L;'  this  jieriod  ihc  primary  cause  in  a  majority  of  cases 
is  the  same:  the  ]n'esencc  nf  a  ^trunioii-  liahit.  In  these  eases  any 
cause  which  may  excite  glandular  intlammation  im  either  side  of  the 
]iost-]tharyn,i;-cai  \\all  may  re-iilt  in  suppuration. 

In  older  persons  the  can.-c.-  are  nioi'c  idiopatiiic  in  their  character. 


!i)il 


oiio-i'iiAitvNX.     i!i;ri;oni  \i{\  m.kai,  ahm  i;ss. 


*i5}) 


C'dcli  iiidividiiiil  ciiso  liciiij;  (It'iifiuli'iit  ii|iiiii  somo  piircinl  cause  <>(  ]\^ 
own.  Sonic  cases  arise  from  caries  of  llie  vcrtelira'.  altliouj,'li  the  |iei- 
centa^fc  is  verv  small:  Mime  a>  -e(|Ue|;e  nf  e\anl  liemalii.  pai't  ii  iilail\ 
M-arialina.  e(|nall_v  small  in  nnmlur;  ami  iii(ii>iimally  nnc  fi'om  liau- 
niaii,-m.  I'eilia|i>  cnld.  aeiint:  u|inn  a  ~rn-itive  llirual,  llie  pliy-ical 
iicallli  liein,ii'  at  llie  time  lielnw  par,  may  in  ailnll  lile  lie  \\\r  me-i 
fri'ipicnt   caHM'.     Sc\   ha.-   no  -|iicial   inlhience.      in  nid  a::e   ii    rarely. 

if   e\el',    oeenr-. 

Symptomatology.  In  children  ijn-  -\ni|iiiMn>  are  iIkim'  altendinL;' 
the  ,-lnu  -ii|i|iiiral  inn  nf  ihe  |ym|iha!ie  L;lands.  'I'here  i~  rarely  any 
chill.  Inn  llie  feeliiiu'  of  malaise.  III-.-  (if  a|i|ieiite.  and  laiiuimr.  'I'ln' 
fe\cr  i-  very  sliiiiii  and  aeeom|ianie(l  liy  ;:railnal  In--  n(  Ih.-h.  I  lay- 
may  elapse  hefure  alieiiiiiin  i-  di-aun  In  the  ihmat.  1  >ei:lin  il  inn 
e'radiially  lieenmc-  dilliciili.  and  may  llnally  lici-nmc  i  ni|iii--ihle.  while 
the  voice  a.->iinie-  a   |ii'ciiliar  (jiiackiiii;'  Inne. 

On  e.xaminalinii  al'  ihe  ihi'nal  the  |in-i-pliaiyn\  uill  he  fniind  tn 
he  -wnjlcii  a-  if  hy  o'dema,  pan iciilarly  nii  nnc  -ide.  lillint:'  up  ihe 
]ihai'yn\  and  pre--inLi'  iipnn  the  toni^iic,  My-pmea  al-o  hccnme-.  in 
many  ca,-es,  a  sci'ioii-  .-yniplnni.  nwin;^-  in  iJic  pres-iire  nf  ihe  plile;:- 
innnniis  sac  iipmi  ihe  larynx,  prndiicin^-  defective  ai'ralinn  of  hlond 
and  more  nv  Ic,-.-  cyaiio-i-.  The  child"-  head  may  hecoine  llxcd:  henl 
forward  slijzlitly  if  llie  discasi'  is  hilatcial  and  toward  the  iinalVeefed 
side  if  unilateral. 

In  adults  there  are  no  liini:-cnnt  iniied  pi'einnniinry  -yniplnm-. 
'Inhere  is  no  ulandiilar  all'e(-tion:  hiit  cmnini:  on  -nddenly  are  the 
direct  .-yinptimi>  of  severe  faucial  le-inii.  This  is  in  the  fnrm  of 
acnte  inthiinmation  in  a  localized  spot,  rc.-ultin^  in  early  suppuration. 
with  rapid  extension  i)itn  tli(>  surroundiiiLT  tissues. 

There  is  pain  in  the  pharyn.x  frnm  the  tirst,  a,ir,i,'ravated  hy  any 
atlcinpt  at  de.iiliitil  imi.  The  disease  is  >ilienie.  ii-iially  ushered  in 
hy  a  chill,  and  marked  hy  a  ri>e  of  .-everal  dcLM'ecs  in  temperature: 
whereas  in  children  the  fever  is  of  a  low  asthenic  type. 

Another  nnlahjc  diiVercnce  is  that  in  adult  life,  while  dcHliiti- 
lion  may  he  exceed in,::ly  painful  and  almn>t  impn-sihlc.  dy.-pmea 
rarely  occurs. 

Diagnosis.-- On  examination  the  ]iost-iiIiarynx  will  he  dark  and 
iSwoihii.  'lid  in  due  tiiiu'  the  j)oint  of  nearest  a]iproach  of  pii-  id  ihe 
sui  face  Will  he  noted  hy  its  <rrayish.  dead  appearance.  These,  with 
the  „feue.al  plileuinomnis  ooudition.  eitiier  across  the  whole  nf  the 
poslerinr  wall  or  limiled  pai'tially  tn  mic  .-ide.  .-Innild  indicate  pretty 


r!/l 


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WEBSTER,  N.y.  MSBO 

(716)  873-4503 


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ill 


III 


•J  GO 


DISKASES   OK     IIIK    I'll  A  li  V  N  X. 


wi'Il  tlic  imluiT'  of  the  disoaso.  Piiljintioii  would  indiciitc  the  i)n'S('iico 
1)1'  |)iis  or  llu!  brawny  condition  pri'dMliiiL;-  it.  'J'lic  same  nii^lit  liu 
.<ai(i  ol'  the  ciircfiil  nsc  (if  tl)o  cotton-liolilrr.  the  clastic  sensation  at 
I  lie  |ioiiii  ul'  snlicniit^'  iicin;,'  iccoiiMi/alile  \>\  citlicr  means. 


Ill   I  lie  astiieinc  ahsee.-s  o 


'iiildhood    ther 


e    I.-    le; 


loeallXeij    in- 


llaniKiatoi y  action,  and  ]ierli;i|i'-  iikhi'  ol'  an  o'deniatoiis  a|i|ieai'an(  e. 
'I'lie  disease  is  also  more  likely  lo  lie  unilateral.  Hence,  from  tlio 
(inc-hided  fullness,  toiictlier  with  llie  indications  from  toiiili.  tic  diai,'- 


nosis  slionld  imt   l>e  dillieiill 


iliroillell  V    III    ( 


liild-life  -lioiild  not 


lie  forjidttcii.     In  al'  eases,  liotli  in  cliildrrn  and  ailiills.  tbe  |ieiiiliar 
eliaractcr  of  voice,  lixation  of  tlic  head,  aliseiiee  of  coii'd),  and  freedom 


irom  tonsillar  comjilication  should  help  to  exclude  all  other  disea>es. 

'J'lie  possibility  of  niislakiiifj;  aneurism  for  post-pharyn^rcal  altscess 
sec'in.s  almost  incrcdilde.  The  stron.Lr  regular  pulsation  of  the  one. 
free  from  all  inllamiiiMlory  aeiion,  should,  liy  sii;ht  as  well  as  touch, 
distinjniish  it  positively  from  abscess  of  the  pharynx. 

Prognosis. — The  plilej^monous  abscess  of  adult  life  runs  it-  course 
ill  somethiiifjf  like  a  weid\.  Then,  in  favorable  cases  it  will  open 
spontaneously,  and  in  a  few  days  heal.  When  lanced  earlier,  the 
conrse  is  shorter.  It  is  rarely  a  dan^'eroiis  disease,  even  if  let  to  llnd 
its  own  o'.illet,  althouj;li  both   painful  and  dislressiiii:. 

In  childhood  it.s  course  is  much  more  |ir<d(mired,  exiendin;.;  over  a 
miinber  of  v  cks.  and  not  unattended  liy  danirer.  rn-uceessful  dia;x- 
nosis  niny  prolong;  the  disease  anil  ciulan^rer  life  from  siiirocation, 
riiiitiire  of  al).«eess  into  the  air-passa,i:es.  or  proloni:ed  ana'inia  and  de- 
bility.    (Kdeina,  also,  miirhl  lead  to  stenosis  and  death. 

When  the  disease  arises  from  spinal  carie<  the  proiriiosis  is  not 
Xood,  inasmucli  as  the  cause  cannot  be  removed. 

In  very  severe  cases,  wlien  unrelieved  by  surjrical  interfcrenee. 
tlicrc  is  serious  dan.irer  of  general  -epiii;emia,  to  be  followed  by  a 
fatal  issue. 

Treatment.- -In  adults  the  treatment  is  almost  identical  with 
that  of  (juinsy.  The  abscess  should  be  opened  as  soon  as  the  presence 
of  ])ns  becomes  certain,  and  the  swollen  and  inllaincd  li.>isues  may  be 
scarified  even  before  the  existence  of  pus  is  discovereil. 

In  yonn;^  children,  considering:  tlm;  the  phliiiinonous  inflam- 
matory condition  is  absent,  scariliealion  would  be  contra-indicated, 
but  openiii>:  of  the  abscess  as  soon  as  discover(>d  should  certainly  he 
done.  As  a  rule,  the  opening  should  be  made  in  the  most  dependent 
part  of  the  abscess,  and  into  the  pharynx.     Cases,  however,  do  occur 


u  ; 


<>it<.-i-iiAiiVNx.     i!i:Ti!nniM!VN.,i;.M,  AitscKss.  ;;'.;i 

i'l  "lixli  .■in  vuvviui]  u.-isinn  is  \hv  lavt;    hut  this  ran  only  he  when 
Ihv  Mi|,,u.ratjv..  Ivniphmic  :h.n.ls  r-.m  hvA  he  ivachcl  in  that  way 

I'onltiun-  in  this  .lis.as,.  ,,,1,  I f  Ijule  avail.     In  juv.M.ihs  tl,e 

<•on.ht.on  IS  loo  asfhcnir  t..  iv.,,„.v  ihcir  a|.|.li,ation.  In  a.luU.s  they 
;"">'"t  'vad.  the  aireete.!  parts.  an,l  h,,,.-,.  are  nseless.  If  applications 
to  the  neek  are  re.|uire.l  at  all.  the  warm  e..tton-woul  n.IIs  already 
iH<rre(l  to  m  tnafin-  nf  .piinsy  are  all  that  ^^nuh]  hv  rcp.ircd  In 
chihlren  alt.r  rxa.ualion  the  application  of  tineturo  of  iodine  to  the 
swollen  ^rlan.ls  nii-ht  h..  pro,|ii,.|ivc  of  -.„„|. 

Snj.portin-  nica.Mnvs  and  noun.hini:  dirf  in  children  are  always 
"1  I'lnee,  an.l  n-uh.tion  ni  ,hr  prlw^r  viv  i„  a,lidl~.  uiih  antiperiodio 
treatment,  niiMhi  h,.  ,,f  s.'rvic.'. 

A.rri:  ixn:.  thus  nii.i:.;MuN  ot  tmi:  ni  miynx  is  an  •■xeeedin-ly 
rnre  and  fatal  dis.-ase.  It  is  speeiflr  ,n  .hararl.r  and  differs  from 
••Hropharyn.uval  al.srrss  in  h.-in^r  mo,-,.  vi,„!..„t.  hut  nm  unattended 
hy  drvrlopnirni  „f  p„s-sa<s.  Treatment  i.  -aid  to  W  support,...'  hut 
uiuivadiii'r. 


m 


M 


I  ii.\i''i"i:i{  MAiii. 


lIVI'Kiniv'ol'IIV  OK  TIIK   I   \r(  l.\L  T(i\SII.S, 


l\    ciirlv    lilr    till-    ili^cil.-f    1>    o.-cll 


tiall 


y    Mil     cllllll  lii'lllcllt     111'     |i!'(i- 


11 


lil'tTiitinii  (iT  ilic  Iviiiiiliiiiii'  tis-iio  of  wliirli  ilir  ii'ii-iniil  t'lnsil  i-  cdm- 


All 


lie  (Iclllrllt.-   n(   lllc    Inll<il   lire   ('ll:^il!.''i'(|    ill    tilt'    |'r(i(T>.-,    lull 


it  i-  lllc  lyiii|iliiilic  (■tll-(Ji'V(lii)iiii('nt  wliicli  is  iliiclly  >tiiiiiil;ilr(l. 

ill  iidiilt  lil'c  Jiiiy  liy]icrti'(i|iliy  oiciirriiitr  in  tlic  lnii<il  n-nally 
iiic.-iiis  liypcrt rnjiliy  .il'  ilic  cniinttl i vc-t i--iir  clcinciit-.  iiml  imt  --o  iinuli 
III'  iIm'  iulciHiiil,  |pr(i(|iiiiiiL:  piiiiiiiiiciil  thickciiiiiL:'  <<(  the  lilmnis  and 
liarriicliynialiiii-  li-.-iic  ut  tin'  tnn>il.  lifiicc  arisrs  the  hard,  smontli 
liyitfrplasia  so  (d'tcii  seen  in  iiini  ami  wnmrii  in  cimi  radistiiiclion  to 
tlic  snl't,  lyniplioid  liyiicrtropliy  ol'  iliildliiMid.  'I'Ihti'  is  also  tlit» 
huiinai'  variety,  not  iiilriMHiciitly  nirt  with,  in  .vliich  tln'  lacuna* 
hccoiiic  lii'cally  distended  with  ca^c(lll^  iiiatlcr.  niakin.ij:  clefts  and 
sinuous  iia.-sau('>  in  the  imisil,  ultimately  invuhinu'  lln'  |iaroncliynia. 

'riieie  i-  likeui-e  what  I'ynehon  lias  recently  descrihed  as  the 
"Suhniei^icd  'ron>il."  heiim  a  condition  in  which,  not witlislandinir  a 
^feiieral  I'lilliic.--  i>\'  the  tliroal.  no  distinct  tonsillar  ciilar;j:enu'iit  can  at 
llr-t  lie  >een.  Chi-er  iii-|iection.  hnucvc:'.  will  rc\tal  the  true  eomli- 
lieii.  In  -oine  ea-e>  the  I'aiicial  pillais  are  urcatly  etilai'LTcd.  caiisinji^ 
an  e\eii  lateral  l'ulliie->  with  the  tonsillar  thickenin<:'.  In  others  the 
cidariicd  ton>il  i.-  hidden  liy  the  plica  trian^rnliiris.  already  descrihed. 
V  hich  soinetimes  extends  downward  and  haekward  Ironi  tlie  inar;(in  of 
lllc  anterior  pillar. 

Pathology.-  In  early  life  there  is  in  the  toii.«il-  an  active  pro- 
liferation iif  lyiiiphiiid  cleiiieiil-.  'I'he  crypts  are  widened  and  can  he 
seen  stiiddiiiL;  the  siirfaic.  The  ciilarLicd  tonsil  tills  in  the  cavity 
hetwi'cn  the  anterior  and  po-terior  |iillar--  on  each  -ide.  standing,'  t.ui 
promimnlly  and  projeeiiiiir  toward  the  illegal  line.  'The  mucous 
iiieiiihrane  i-  niicliaiiLied.  dippinLi'  dnwii  within  the  fold-  uf  the  crypts 
niiicli  as  in  health.  The  papilla'  arc  ciilariii'd  and  llatlciicil  hy  the 
(lislension  of  the  or;:an.  'I'he  lymphatic  liodies  are  nofahly  enlarged 
and  the  hlood-vesscls  increased  in  siz(>  ami  niimher.  while  the  con- 
nective-tissue lihres.  even  in  (hildhood.  may  he  increased,  interlacing 
mil  liindini;'  toLi'eiher  the  lymph-hodies  as  a  whole  {\'\is.  Si). 


oito-i'iiAKYNX.     in  ri:i{i  lioi'ii  V   ui-    riiK    iunsii.s. 


•H\:\ 


'     I 


111  adult  life  tlif  iiiiliiral  tcmlfiicv  l..nanl  >liriiikaL,'<'  "f  tln'  l_vm|ili- 
tisstics  is  usually  apparent,  tvcii  in  ra.-.(-  <■['  cxlrii^isi'  livpcrtropliy. 
Tlif'sc  hollies  may  have  lieen  ciihirL'ed.  Iml  they  are  ImmiikI  (\n\\\\ 
liy  the  e(i|ll,eetive-!i.-Slie  ;:lnu  ih.  I 'ruli  t'rl  ;it  n  Ul  enlitilllles;  tile  crypts 
llieiiiM'lve^  are  ii)\aile(l  niilil  ihey  aic  nh-i  ni(  ted ;  ami.  in-tead  nt  ihe 
(•pen    i'.dlleies    wlliell    "re    jnliiid    in    t!ie    miimal    nv    I'Ven    ill    tile    liypef- 

tniphieil  tnn>il.  tlie  .■-...ixiili.   fniindid.  liyperplaslie  siiil'aee  is  lei't    in 
its  place.     'I'liis  h\  pi'iplastie   tun^il   thiw  ennsists  of  hiiiidles  ol'  vi>\\- 


M- 


?   I 


■'"\.i^f::.r>:: 


-f 


I'i^'.  >^l.  Siiri|i|i-  li\  |iiil  rii|ili\  111'  l.iiiii.ij  |iiii-il  i  .">7  il  niirlfr^i.  (/. 
Strut  ifii'd  -i|iiMiiiiiii-  i'|iitli('liiiiii.  I>.  (  niiini  ii\(  t  j--U(  \:;.,--  i  niMiiinititr 
lil<Ki(l-vc»ils.  I.  M  lie  II- •^I'cri'l  in;;  ;:iiiiic|-.  '/,  l.\  iii|iliiiiil  li--iii'  inniainini,' 
fiii;r  iiiiiliilc«.     I.  i;|iii  licliimi  iif  I  r\  |it      /.  (.i\ii\   iii'ii\|ii.     i  .\iil  hen  >  ^inci 

incll     li\      l'.rll-li'\  .  I 


.'     1 


nect  i\('-tissiie  elements,  eiiiitaiiiiiii  iiludd-v  e-~e]s.  nerve-,  and  -hfiinki'ii 
lymplialic  hodiiv-.  In  this  j'ni'm.  I'foni  the  -iipply  nf  hhind  heini: 
limited,  the  surface  is  snnielimes  n\'  a  paler  line  than  natural.  Winn 
the  lacuna'  have  heeoinc  ilisternhd  iiy  the  -iiietinn  nf  ea-eoii-  niatter. 
this  ran  lio  sijueozed  out  readily  hy  prc-siire. 

In  other  instances,  the  hypertrophic  foi'm  of  ehildhoocl  doe-  imt 
niateriallv  (haime  as  mature  var-  are  reached,  aiiv  enniiective-tissiio 


-'    t 


Mil 


I)ItiKASi:S   01     Tin;    rilAKVNX. 


(IcVfllipllKIlt    cilllv   illi  icil^illi:  the  L'flHI'ill   Clllill'ircllR'nl  Ol'  lllO  Iliafl.S.       1  •(? 

Siiiioni   ^pcjiks  iif   ilic   ilivcln|iiii('iii    (if   vOi^ctalilo   jianisitof,  or   hlas- 
Iniiiyccii «.  ii>  nil  iiiliiot  111:,'  liist<iliii,'ii  al  Teat  HIT  associated  with  clirnnir 

tnlisilllti.-   ill    lllr   IlLlllt   (it  flinldirv. 

As  a  lull'.  wliati'MT  tlif  tnrin  nf  liNpiTtrojiliy,  it  is  IiilatLTal, 
tliiiii;^li  il  i.-  I'arc  llial  tlif  lun  >iil('s  arc  I'ljiially  ciilarLM.'d.  'I'lu'  l»i- 
liilcial  <iiii(litinii   is  cdiHidi'icd    in  hr  an    iiidicatinii  id'  the  diatlu'ti(r 


iiiitiirc  lit  (lie  di-ca>c.     'I'lii,-.  1 


inUrVc!-.   dncs    lint    did    lllTc;     liill,    \*!l('ri 


We  liavc  dniilili'  liin.-illar  h_v|iiTl  ni|jliy.  ihcii'  is  usually  eiilaru'riin'iit 
(d'   tl.i-    |iliaryii::i  al    tniisd    likewise. 

Etiology.  -Tliis  iini  iiiriei|iiinlly  is  a  ciuiueiiilal  CDinlilidii,  llie 
eiilar,L'eiiMiil  liaviiiir  ciiiiiiiieiii  i  d  piinr  lo  liirtli.  as  a  iiiaiiifestatinii  of 
■1  l_\  iii|iliatie  nr  .-Iriiiniiiis  diallir»is.  .\<  a  rule,  the  hy |iertrii|iliy  cnm- 
liielKes  diiriiiLT  ehildlindd.  a  lar;ie  perci'lita^e  of  thi'  eases  heiui:'  de- 
\e|ii|i(d    eiulicr   tliiiu    tlie    telllll    ;e;ir.       r.isllo|l    phU'lIS   tllO   hu'^'est    IlUUl- 

lier  (if  ea.«es  hetweeii  the  tenth  and  twentieth  years.  Prohahjy  all 
( ii.M-  iiceiirrini,'  al'tt  r  tlu-  latter  a^e  are  (d'  cither  hypcriilasiio  or  lacunar 
l'(irni. 

The  diallietie  liahit  wiiiild  ualiirally  invnlvc  the  hereditary  in- 
llneiice,  and.  Liiveii  this  tendency.  trc(|ueiil  exposures  to  cold  wniild 
kccj)  the  throat  cdnstanfly  lialde  to  attacks  of  inllaniinatory  di-ea«.', 
while  each  attack  would   lia\e  additional  enlargoincnt. 

In  the  same  way  the  exaiitheni.itiuis  diseases — scarlet  fever, 
measles.  di|ihthcria.  etc.-  all  of  them  fre'juenily  leave  in  their  trail 
the  conimeneeineiit  (if  (let  |i-.-eated  tonsillar  hypertrophies.  Conjii'iiital 
syphilis,  too,  is  said  to  he  a  pnlerit  (dement  in  tiie  production  of  this 
disease,  while  tlie  rh(Mimalic  hahit.  leadiiii:  so  frocjucntly  to  pliaryn- 
iri'al  rheiiiiiaii-ni  in  adiill  life,  is  the  direct  cause  of  many  cases  of 
severe    hyperpla-ia. 

Symptomatolog'y.  In  (hildhond  the  external  appearance  of  the 
face,  without  examination  of  the  throat  at  all,  is  almost  siinicieiit  to 
indicate  the  presence  of  the  di^tase.  at  least  sutVicient  to  divide  the 
cause  with  adenoid  ciilarL'ciiient.  1'lie  facial  symptoms  are  those 
spoken  of  in  connection  with  that  di-ease.  altluuiLdi  they  are  prohahly 
exa;i'frei'al(  d  more  in  pharyii;.:('al  than  in  faiicial  hypertrophy.  When 
the  ton-ils  alone  or  in  comhiiiation  with  adenoid  enlarirement  are 
sidViciently  liy|»ertrophicd  to  prodiu-e  nasal  stenosis,  the  facial  symp- 
toms heconie  vr-ry  apparent.  The  vacant  look,  the  open  mouth,  the 
pinrlied  nostrils,  the  oral  llreatllillL^  may  all  lie  present:  while  ster- 
torous respiration  and  restlessness  are  regular,  nocturnal  .symptoms. 


ui!<)-ni.\i!'i  NX.     11  vri;i(ri;nniv  (»r  nii:   rovsii.s 


xm;.. 


'riicso  syiii|il<itiis  iU'i'  all  nl'  a  inccliaiiiial  cliaiadrr.  Tlio  (nii-il- 
nct  like  IniciLMi  Imilics  olislnictiiiLr  lln'  tliniat  atul  iiasd-pliarvnx  ami 
prcvt'iil  iiil;'  nnniuil  na-al  lircatliiiiLT.  'I'liis  lurciil  juiil  iniiliiuicil  sii>- 
jii'iisiipii  111  iiatuiiil  ii  .-iiiralinii  inuls  lo  iirmlm  r  jiliaiv  iiL;ial  cniiu''""- 
linii.  rr-iiliiiiL:  III  i!i(i'i'ii-(  (I  h\  pell  in|i|iv  Willi  ijicli  1 1 1  lla  iiiiiia  t  >  pit  attack. 

I!iiiipariii>-((1  ri'>|iiiiiliMii  i-  niiniliM  !'r>iili  uliiili  nrim  ucciir.-, 
|iart  iciilaiiv  in  early  lilV.  ami  in  lailillir  ov  .•.crdfiilnii.-  -iilijccts  is  likt  l_v 
tci  lie  I'dijiiunl  I'V  clii'-i-dcl'iirniily.  The  vnicc  aUii  ln'cnmo  alVi'cti'il. 
ndt  niily  with  ilic  -i)-rallc'il  na>al  tuan.::.  I'lii  al-.i  I'lnm  a  tliiik.  inutlliil 
tunc.  I'c.-iillin::'  fi'niii  iiniialiiial   [iliaryiiLifal   fullness. 

I 'I'L^lniiiinn  i-  iiwl  iiiihii  inii  rliTid  with,  f.\c('|it  in  ydiinu  infant-, 
wliiii.  a.-  in  the  (iiM'  (if  aili'imiiN.  llii'  inijins^iiiiliiy  of  munial  iia.-al 
lircai  liMi.u'  |ir«'vcnts  ihc  child  frmii  nur-iiiLr  \\iili  any  mnilnii. 

it  is  (|(iniitfiil  whcthci'  ciilai'ucnicn!  of  the  fam-ial  tnii^il-  has  the 
(•i''ict  upiiii  the  i'ii-;acliian  liihcs  n-iially  a-^iirmil  tn  it.  There  ai'i' 
III!  'nilitiMlly  many  cases  of  deiifiiess  .md  chronic  i:\v  disease  a>Mi- 
cial.  !  with  tdii-illar  liy perl mphy ;  Ini!  it  nin-t  he  cuiiceded  that, 
aliiiii-i  iiuaiiaidy,  iiDtaMe  hyperlnijihy  nj'  the  faiuial  tnnsil-  is  aei-nm- 
paiiiid  iiy  eidarL;cnieiit  >'\'  the  pharynuial  |nii~il;  and  iliat  it  is  to  the 
lallci'  that  tho  pros-nre  upon  the  Mii-lacliian  tiilie  is  due. 

|-;xccssive  tonsillar  st  i  n  linn  is  imt  a  characlerislic  (if  this  disease. 
Chee-y  conci' ■!  iii!i>.  hiiU(\(r,  aic  depcsited  in  sdiiie  ca-e-  within  the 
laciiiiM'.  pi'ddiiciii::  -ofcnc--  hy  their  pfe^cm-e  and  an  (iir(  ii-i\c  imIhi- 
frmii   lull::-  icieniinii. 

Diagnosis.  - 'riiiifiaiuh  exaniinalimi  with  m-  witlidiit  rcllocted 
liu'lil  -hduld  in  all  ca^'S  '•(■  siillicieiit  to  estai'li-h  a  correct  diai;mi-i-. 
To  in>iiro  this  flu,'  toii-il  -li"iild  he  examined  in  two  position.-:  1. 
Willi  the  po>tcri(ir  faiicial  pillais  in  their  iialnral  relaxc(l  po-ithm; 
that  is  when  the  iiKUitli  is  wide  open,  the  anterim'  and  posterior  pil- 
lars standing;'  parallel  with  each  (oilier.  'I'liis  can  ii>iially  he  accoin- 
plislie(l  liy  ^(Mitly  depressina'  the  toni:ue.  If  eii!ar;.:(d.  the  tonsils  will 
stand  out  prominently  hcyoml  the  pillar-  projectiiiLi  toward  the  medial 
line.  '.'.  ^\'ifll  the  pn.stcrior  pillars  drawn  tiLdilly  and  tlie  toiiLiiie  well 
depressed.  I>y  this  nienns  the  toii-iis  are  thrown  fare  fiu'waid  and  all 
the  iiie([nalities  and  irreiiularilies  n\'  outline  iKcnine  dislim  tly  \i.-ihlc. 
They  arc  not  only  tiirneil  fiuward.  Inil.  in  a  mea-nre,  iii-ide  cut  a-^ 
well,  the  deep  snlci  and  wide  clefts  which  so  often  occur,  and  whi(  h 
remain  unnoticed  in  the  mirinal  positiini.  liein^'  hroiiLdit  into  view. 

It  is  said  that  there  is  sonietimos  danLrer  of  niistakinLT  an  enlar;:ed 
tonsil   for  a  tonsillar  ahsccss.     The  latter  is  attemle(l  hy   fever,  pain. 


I 


•.'(!•» 


iii>i;  \>i;s  oi'   I  in;  ni  \it\  w. 


jiiid  pcritnii-illjir  t'iilliii,->.  wliicli  n-c  nil  iili»riit  in  tlif  Iniiiicr  cDiidi- 
tioii.     I>i;:iiiil  ('MiiiiiMiilinii  ^limild  rt'iimvi'  iitiv  rciiiiiiiiiiiL'  ilniilit. 

Ill  iil'lri-lilc  iiiiiliitiTiil  (•iiliir;jt'iin'iit  licluicii  llic  pilliiis  iniglit 
;iri.-c  t'l'i.m  iiiiiliL'iiiiiit  (lisr;i«('.  Init  the  (listiii'_'iii-liiiiLr  Iriitiin'S  of 
(■;l(lic\i;l.  IKllli'  |i:lill.  liml  l;i|M(l  (iiljilLirMiciit .  Ultll  icilninii-.  il  i-i|iar<£e 
\\lii(li  (li-I iiii:ni-li  ciiiirrr.  wniiM  [ircvciii  a  wrimi;-  (liiii:ii(i-is. 

I   liiui'  >ri'ii  niii'  cii-c  ulinc  Irli  iiiitsiiliir  lilinniiii  (Irvt'lojicil  in  a 

lilUVcl'.     ilLIl'il      I*.     Mijllr     lilllc    IlI'ltT     illl     llV|>cr|)li|>iic     tn|l<il     ll;|(l     lici'M 


ri'iiiovcd.   hill    till'  u  hie 


I'.'icl    ii    iiiiL;lit    liinc  licrii   1 


iKrll     jiir    ;|    -IIIIIIH' 


|oll>ill;ir  cllliir^jclllrlll.       il    u;i-   ill-n   1 1  i-t  i  IILI II  i-lli'il    I 'V    ils   wllilc    lilirnIM 

cliiii'iirlci'  ;iih1  ihi'  .-lidntiiiL:  piiiiK  uliiili  |i;i>»i'(l  in  (lijl'crciil  ilirn  i  ions 
Irniii  il.  Ii  was  ,-('<>ilc  mill  |ii'(iiiiinriil  and  initircrcil  with  tlic  use 
111'  the  \(pi(r.  Il  was  rriiinMil  liy  rc|icalcil  uahaiiuraiilcrv  n|iri'alii)ns 
and  did  imt  rtliirn. 

( >(iii-iiiiiall  V  a  liiii-illil  II.  liiirird  wiihin  ihr  ;:l;:nil.  will  cause  in- 
1  nin  ciiiriirf  hv  its  >'\/.c  aiid  iiiav  lir  iiii-takcii  I'm'  ~iiii|ili'  liy|pcrl  rophic 
Irsinii. 

Prognosis.  Tlif  naimal  iciidcncy  is  lor  tlir  tonsils,  wlini  not 
M'rioii«|\  riilarLii'd.  In  -lirink  awav  irradiiallv  ami  lir  alisorlicd  during' 
till'  (•arlirr  year-  id'  inatnriiy.  .-o  that  a  iihti'  sciiililaiK-i'  of  tin'  tonsil- 
lar li^-iic  rciiiaiii-.  And  uhcii  licariiii;  i-  iiiialTi'i-tid.  wlnii  respiration 
is  normal,  and  ilicrc  is  no  tendency  to  -oi'enes>  oi'  the  throat,  even 
if  the  (oii^ils  are  liyperti'opliie.  Nature  ~h(nil(l  he  allowed  lo  do  her 
own  prc>criliiiiLr.  Jind  the  toii>ils  left   >e\erely  alone. 

•  til  I  he  oil II  r  ham!,  w  hen  they  are  -erioii-ly  eiilar-ed.  oral  hiealh- 
iiie'  heiiiL;  one  of  the  result-,  there  is  >eri(ni.-  ri-k  to  ihe  health  of  the 
patient  in  ,-e\eral  ways.  Not  only  doe-  the  iiii-al  -teiio-is  deprive  tlie 
air  (  f  re.-piration  of  the  ndvaiitai;i'>  of  -aliiration.  elenn-ini:.  ami  lieat- 
ini:.  wliieli  nasal  hreathine-  pi'ovidrs.  Imt  the  open  mouth  makes  tlio 
eiilai'Lied  lon-il--  -till  more  -u-cepi  iMc  lo  irrilalion.  'I'he  ;:erms  of 
disea.-e  llMatiii::  in  l!ie  air  liml  ii  ready  imhis  fur  de\e|opment  in  the 
open  -lllei  of  llie  toll-il-.  'I'lli  -e  lai'l^e  Imdie-  are  partiriilarly  .-U-- 
eeptihle  to  infection,  and  il  i-  ue||  known  llial  children  haviiiir  ton- 
>illar  liy  perl  ropliie-  are  more  prone  to  the  di-eaM'-  id'  eliililliood  than 
tho-e  v\ho  do  not  po--e-s  them.  I  lypcil  rophied  ton-ils  are  al-o  liahle 
to  attack-  of  ipiiii-y:  ami  when  children  'jiow  up  to  adult  aL;e.  with 
hvperlrophv  LiiviiiL^  way  to  liypcrpla-ia.  the  periodic  attack-  nf  ipiin-y 
often  continue  for  year-,  eon-lanlly  iiicrca-iiii;'  ihe  comiecl  i  ve-tis-iio 
development . 

Treatment.     Medical  ircaliiicni   for  eiilarucd  lon^iU.  Imtli  inter- 


oijiii'ii  Mivw.     II  vi'i;i!i  liurin    or  mi:   inN>ii.s 


!i;il  iiiiil  Infill,  liiis  so  frc'(|iiciitly  lictii  liirtl.  nml  uith  siicli  iiiiit'ormly 
iiii.siiti.-fiutoiy  rc.-iilis.  tli;it  il  i-  iiliiin«i  ii^(  It -.  til  ^pciik  (if  it  licfi'.  It 
is  pos.-'iMi  lliiit  ill  iiiilil  (ii^i>  llii  liiiiil  ;i|i|ilniiliiiii  111'  iiidiiii'.  Ill',  wlicic 
tlici'c  i-  iilniiv  (if  ,-_v-lciii.  tlu'  ;iiliiiiiii>i  nil  Mill  df  imlidc  (if  inui   inirr- 

llilliv    lllllV    lie    (if    .--'line    llM'.       Sil    ill.-ii    il.-llillL'i  lit    .Liiir.ulfS    n(    llllrturc    III' 

11(111  111  Miliilidii,  (If  llic  liic.il  ii|i|i|i(aliiiii  111'  iiilralc  ol'  silver,  iiiiiihl  he 
tried  III  cases  in  uliicli  I'nr  variniis  realms  ii|ieiali\e  trealiiieiil  wmild 
ite  iiia|i|iliealile;  liiil.  uleii  .-t  ridiis  >_viiiiiiiiiii>  aii-e  I'lmii  the  luc-eiice 
id'  tlic  li_V|ui'ti'ii|iliie(|  iiia.-ses.  eNtiipalinii  i.«  liie  niily  rea.-niialile  treal- 
iiieiil. 

Of  course,  liefnre  ii[iei'atiii,i,',  it  i-  always  iii>(  to  .xciire  the  coii- 
.-I'lil  iif  the  piltieli!,  or.  ill  the  ca>u  of  ehihlicii.  the  coli-eiil  of  lilt' 
;,MliU'(liaii   ill  (  haiue. 

'The  various  method.-  of  operalion,  hy  iMi.-iiin  with  cuiAed  scis- 
sors, histoiiry.  ,i:alvai!ocaiitery-kiiife,  cold-uuc  -nare.  ualvaiim-aiitery- 
Miiirc.  'ir  hy  llu'  various  toii.-illotoiiies,  all  have  ilieir  advocates.  Uiil 
the  la>l  iiielliod,  ill  all  cases  where  the  loii.-illolniiie  or  ^'uiHotiiie  can 
he  iiseil.  i~  ilic  one  liiost  L'ciierally  ado|iied  |  I'lir.  .s".'). 

Ill  all  ca-es.  htd'ore  ojieratiiiL;  the  throat  -lioiiM  he  thoroiii.flily 
(•leaiir-ed  hy  the  ii,-c  of  an  alkaline  .-pray  or  di-iiih'cl,iiit  ihroat-wa-h. 
And  it  is  he.-t.  when  a  Liciieral  aiia'sihelic  is  imi  u-id.  lo  paint  the 
tonsils  freely  with  a  I'l-pcr-ceiit.  .-oliition  of  (niajne  or  i  ucaiiie.  I 
sec  no  reason  fnr  iiidiicinL:  iinnceo.-ary  p.iin  in  any  |iaticnl,  and.  as 
ihc  diiiL'  i.-  ciiiinly  under  the  cniiliol  nf  ilic  opiraiinu'  .-nrL''eon,  iherc 
need  he  no  ri.-k  whatever  of  forinini:  the  narcctic  hahii.  hy  its  judi- 
cious application.  The  iDcainc  may  not  make  the  ii.-c  of  iii.-iruinenls 
entirely  painless,  hut  it  will  jiiatcrially  l(\-;scn  the  sulVerinir. 

As  the  majority  of  patieiiis  re(piiiinj:  tonsillotomy  are  children, 
1  ha\c,  as  a  riih'.  found  it  the  he-t  plan  lo  adinini-ler  a  Lieiieral 
anie.-lheiie  to  lluiu.  W'iiile  it  may  he  ipiite  po-sih|c  to  adjust  the 
instrnmcnl  to  the  iir.-t  tonsil  without  cxcitinjj;  the  ehildV  alarm,  the 
-eooiid  adjii.-tnienl  \Mii,ld  lie  iiupos>ihIe  without  piovokiii::  terror  as 
well  as  resi.-tance.     I'.\   iwiiii.:  an  aiuc-thc!  ie  hoih  of  the>e  are  avoi(h'd. 

I'dr  performiiiL^  tonsillotomy  many  varieties  of  iMiL-iildtomc  arc 
in  the  market.  1  think,  mi  the  whole,  however,  that  Mathieu's  is 
to  he  preferred,  particnhii'ly  with  its  ino.-t  recent  niodilication;  that 
is,  with  smooth  spcijr-points.  the  harhs  near  the  ends  heini.'  ronuivcd. 
Tlioy  iirc  iiiteii(h'(|  to  hold  the  tonsil  for  extraction,  after  it  has  hcen 
excised.  This  would  seem  to  ho  nnnecessary :  as  in  iisim:  the  ncwnr 
instnimeiit.  the  tonsil,  in  my  experience,  ha>  always  remained   iipotj 

IT 


; 


m 


M 
i  f  - 


VtiN 


nisi;\>l>   n|-    I  hi;    I'HAUYNX. 


tlif   jMiints   iIiiniiLr   rxttiHticiii.    iintwiiliMjiii.liiiir   tlic   alisi'iice   of   tin- 
lijirlis;    find  cuiilil  I,..  .|i|i|if(|  nil'  more  ivji.lily  .il'tiTWiird.     One  liciiutv 

of    |lll>    idslllllll.lll     is    the     liMUCr    nf    ;i(Iill>till;r    d,,.    ,.x.,ct    iUIKUint     of 

Iriictiiiii   Villi  di'sirc  lo  niiikc  iiiinn  the  tdii.-il   l.y  inrinis  n\'  the  siTtnv 
in  the  s|.riir-lil;Mlr.     Tlif  nnlv  niiilt  witli  ili('  instriimciit   is  the  fiict 


I'i-,'.  S2.— Mad'.ii  u's  tonsillotomcp. 

lliaf  it  i.s  oomposcd  of  distinct  segments,  and  rp-piircs  to  1)e  taken  io 
piocTS  to  l)c  disinfootod  and  cleansed,  after  earh  operation.  Still, 
tliis  only  takes  a  minute  or  two.  and  ean  he  attonded  to  eaf^'ly  I'V 
any  nurse  or  assistant. 

In   applying'  the  tonsillotomo,  the   patient  holding   the   tongue 


iiu= 


(tKo-i'iiAitvN\.     II  vn:i!i  liuni  Y  ni    I  mi:   iun^ii^ 


•Jtl'.t 


•IdWii  ;it  till'  liiiif  wiiii  the  i|i  pressor,  it  is  im|p"rljiiit  to  pii.-s  ilic  iii- 
>tniiiii'iil  Will  iiVft-  tlir  lowi'i'  |iiirt  of  the  tnM.sil,  ji"  this  iiortmii  is  ortcii 
pciiiliildiis,  ami,  Ix'iiiL'  situated  lnw  ilnwii  iii  tlu'  |iliai\vn\.  iiiav  rscapr 
<»l)M'r\ati(iii.  iiiili.'S  (liif  rare  is  taken.  'I'lic  ri^'Iit  liaml  \\\\\  hold  the 
in.-tiiiiiiriii.  w  liielifvcr  >idi'  is  dpeialed  iipdii;  aii'l  the  tnii^ij  ran  he 
held  liiinlv  III  lnuanl  ihe  pliaiviix  li_\  niii^idc  |iic..«iire  nl'  the  lell 
hand.  There  i-  thus,  iiudir  ((.laiiie  ana-lhe-ia.  im  iiet-e.«.«ity  t'nr  tin 
pre.-(  lice  (>{  ail  a.'.-i.-iant. 

Allhiiiieh  the  tniisils  can  nficii  he  reninvid  wiilidiit  ihe  aid  nl 
rt'llceti'd  li,L'hl.  Vet  uheii  it  i-  a\ailalile  it  i-  al\\a\,«  helter  lo  use  it. 
'I'lie  iijieralnr.  >ciii((l  dnccilv  in  I'lnin  nt'  the  jialieiil.  can  hy  it- 
relleitinii  mc  the  pail-  innch  iiinrc  elcailv  and  adjii-t  hi-^  iii-l riiiiient 
with  more  picci>ioii  than  he  diherwise  eoiild. 

In  caseo  aiiioiii;-  children,  in  which  ^(  inial  ana'^'he-ia  i,>  ie(|iiiici!. 
(■thvl-luoiiiidc  or  nilioiis  oxide  may  he  ailministi'reil  m  the  inclhod 
already  nieniinncd.  And  in  \iew  of  ihe  expcncmr  nl'  other  men,  and 
ill  llic  li;jlit   of  hi.-loiy,   I  raiiie-ily  re(()iiinieiid  oiic  nf  the-e  drtiL:>  \" 

he   ll-cd. 

Still,  ill  my  own  piiuiuc  I  have  herelofdre  ii>e(|  chlornl'iii'm  iii 
tlu'so  cases,  th  iiu'thod  hciim  •"  havi>  it  administered  jnr  ijutlitliiH. 
and  not  to  i:i\c  sulVhient  to  produce  vciy  profound  ana'-lli<'>ia. 

'I'he  child,  when  ready,  is  turned  o\cr  mi  it-  .-ide,  with  it.-  face 
toward  a  piod  lii:!it  and  the  tonsils  reiiio\rd  in  ipiick  .-ucec,--ioii.  'The 
hudy  i~  then  rolled  to  ncmly  a  prone  po-ition,  the  In  ad  iieiiiir  held 
over  the  side  of  the  coiuh  to  allow  for  the  e,-capc  of  hlood  into  the 
howl  hcitealh.  In  defence  of  in\  po-iiioii  I  may  -ay  that  in  a  pio- 
I'l'ssional  cxpcriciici'  uj'  thiiiy  \c,ii-,  and  covrniii;  ihoii-and.i  of  ca-e.- 
iii  which  liciicial  ana^tln-ia  ha-  hecii  icpiiird,  for  one  opeiatiuii  or 
another.  1  have  iml  ,-ccii  a  ihalli  occur  from  it-  ii-e.  either  in  my  o\mi 
practice  or  in  that  n|  jnv  of  my  pi'o|'c--ional  lucthri  n. 

lUoedinjx  after  ton>illo!oiny.  altliou;:h  u-iially  free,  is  rarely 
scvcri'.  lastiiiir  only  a  few  iiiinu;i,-  and  'jiadually  cea.-iiiL;.  .A  uood 
many  ca.*cs,  1io\m'\  it,  have  hei  n  ii  >  oiilnl  m  w  liirli  the  Ikciiioii  ha^e  was 
alarmiii!.:'.  This  has  alnio-i  invariahl'.  occiirred  in  adult-.  ()ut  of  'h 
recorded  cases  only  1  or  o  wcie  youn;;!  r  lliaii  I')  years.  With  some 
exceptions,  the  idecdiniT  oceiiired  imimdiafely  after  or  within  a  few 
Inuirs  of  the  operation.  Two  df  the  former  were  in  my  own  practice. 
One.  a  slmn^f,  jilethoiic,  medieal  tiidciit.  ua-  attacked  hy  -ecoiidary 
ha'morrha''('  on  the  liftli  dav,  after  o\er'\eriion.     The  other  was  the 


:i-  f 


i 


v-  ■ 

I; 


Iii  tie  a-vear-old 


n   of  a   |ihy-ieiaii.      In   hi>  ca-e  the  hloediiii,^  came 


I 


a7o 


i»i>i;a.»i:>  hi    i  iik  ni  \io  n \. 


fill    wllilr   -IlTjiillL'    ill    tlic   i;lllv    lllnfllillL'.    I"""!!!'   illlil    .  inc-llillf   (lny-i   illlir 

()|H'nitinii.      Ill    lidlli    ciiM'S   the    lii-'iiiiii  rliiiy;t;    Wii-^   .-Iniiitcd    willi    littli' 
ililliciiltv. 

It   is  I'dTl  iiiiiilc  lliiit,  \utli  :ill  ;lii\.c  cii-c-  nf  Ml  cdiiiL:.   I   li;i\('  so  fill' 
III  I  11  iinalilr  III  liml  ii  r.'isc  rnnnliil  in  wliiili  li;i'iiinrrli;ivi'  Irnin  tnii-il- 

llilnlllV     IlilS     lUllMMJ     lUtill. 


Kx.'i^ 


imi    liV    llirilll-    111    (  lir\ri|    Mi».nrs   (IP    li,.Iii|irV    i-    llli|ilir;llilr    !■ 


lITi  ;:lllilll\ --illl|n  i|    |ii|l-iK.      Siilllr  (ipiTnlnrs  <j,)  -n   t'lir  il-   In   ri'ciillllllrinl 


till'    llirtlliiil     Jul'   ;ill 


ril-r 


A  I'irr   rm  irii/;lt  lull. 


Ilr    liilmllr    jirjll''    ili' 


|irr-M'il.    Ilir    ti'll-ll     I- 


•i/i'il  liv  ii  \  iil-illiiiii  111'  Iim.iIhiI  l'iircc|w.  iiiul 
aiilcil  li_v  nllrctril  lii:lit  tlir  lthw  lli  is  cut  aw.iv.  'I'lli-  initiinil  is  Ilinsl 
siiiliililc  til  cii-cs  iiiTM'iitiiiL:  inciiiiliir  |i|iijrctiiiii-.  in  uliiiji  llir  tmi-il 

jotiillM'  riillM    lint    III'   il|i|iliril. 

Tlic  iiM'  III'  llic  riilil-uiir  -niiic'  mill  aUn  I'n'  i;al\aniMaiii('i  v-siiair 
lia\r  cai-li  liail  llirir  ail\niatr>.  part  iiiilai  ly  nii  llir  i^rniitiil  llial  liv 
this  iiicaiis  liM'iiiiiriha.i:r  wmilil  lir  av..'i  .il.  Wlirlln  r  nii  arrniiiit  nl' 
till'  ililliciilly  in  a|i|ilyiii^  ilir  wnr.  tli.'  |ia;ii  nf  tiir  njiriatinii  ilsilt', 
111'  llir  (iiiiiral  sliiiii|i  tlic  'i|i(  rat  inn  i-  apt  tn  |ca\c,  uv  all  cnniiiincij. 
tlii,-  iiictlinil  lia-  imi  liccii  rcicivcil  with  uciicral   t'avnr. 

Oiii'  nllicr  iiicllinil.  n|icratinii  liv  ;:a I \ a iinca  11 ' ii'\  k 111 I'c.  remain- 
tn  lie  coii>ii|crcil.  In  -iiitaltli  rases,  |irn|>eilv  ,-elciicil.  im  nilirr  iii- 
striiiiieiit  that  I  kimu  nl'  can  iln  as  cH'cieiit  wmk.  It  i-  parlicularly 
siiiteil  tn  tlinse  irrcLMihiiiy-i  |n\ cii  tnii«iU  which  \\c  nl'icii  meci  with. 
Kmil  .-ecret  inii>.  jnailcil  with  pal  lin;:enic  Lii'iin-,  I'nrin  williin  llic  cleft-; 
iiiiil  nti-repeateil  attack-  nf  -lire  ihmai.  ri-iili  in  liv  pi  riinphy  nl' 
irrcLiular.  parciicliyiiiatnii-  iiia--e,-.  In  the  hanl.  hypcrpla>iic  imisils 
ol'  ailiilt  lite  the  ;:al\aiincaiitciy  t  rcat  iiiciil  can  al-n  lie  n-cil  In  ail- 
vantaiie.  ('Iicc>y  masses  arc  cnii-taiiily  rnrmiiiir  within  the  ilccp  ami 
iiarri.w  ciypts.  lU  llicir  pn -ciicc  they  pnnliicc  a  iinnil  ileal  nl  irrita- 
tinii;  ami  liny  lan  niil\  he  reimiveil  hy  ilirect  p|•c-^llrc.  .Neither  nl' 
t!ic.-c  varieties  are  nf  a  rnrm  tn  ho  seize. 1  ciVeetiially  hy  the  inn-illo- 
tniiic.  They  ai'e  |irnliahly  al-n  inn  hard  nr  Inn  lilimii-  in  yield  readily 
to  citlltM*  hislnliry  nr  >cis-nis. 

The  nrdiiiary  mcihnd  adviMil  in  ^iich  caM'S.  when  the  i^ahano- 
caiitery  is  cnn-ideicd  In  he  ihc  pmpcr  iiisi  rnniciit.  is  to  make  a  iiuiii- 
licr  nl'  jiiiiictiires  with  the  caiitcry-iiccdlc  iiitn  llic  face  i)\'  the  Imisil, 
iiml  after  an  interval  of  several  days  in  repeal  tin'  npciatinn.  When 
tlio  trrowths  arc  very  larirc.  this  methnd  is  said  tn  take  almiit  twenty 
operations  to  ell'ei  t  a  cure:  no  dnuhi  a  tcdinii-  and  |iaiiiful  process 
to  the  jintieiit. 


I 


ui!ti-i'ii.\ii\  NX.     in  ri.i;i  liiifin    <ii    iiii.    iiin^ii.>.  v  ,  I 

[f  wniild  MTiii  nii.-iiniililf  III  limit  miitfriiilly  iIm    iiiiimIhi  nf  uptr- 
jitiiiiis  iiiiil  hImi  llif  tiiiK'  ii'iniiicil   lui'  ihr  wmk.     All' r  tliiiriiiii:li  m- 

niilli/lltiiill  Cilcll  lillir  tllr  rilllti  rv-lsiufi'  ill»trili!  nf  ll'i'llf  Illli;lll  lu' 
ll-(i|.      Tlie   li|i   lirillL'   lii'Ill    III    li,L'llI    illlLjIi-   III   till'    iilililr,  Jllnl    lili'll    (  ilM'- 

liiliv   ii\iiiilitiL:    till'   iiilliir*   iiml    lliiir   iinn'ii   :it    tlu'    ii|ini'i'   ;iiii:li'.    the 

isllilV    is    ji;l->ril    ,'lt    11    lili;.'llt-lril    (if    wllili'    lliilt     trulll    In|i    til    !iii||(i|ll    III' 

till'  .-iriictiirc  to  111'  I'ciii'ivcil.  Tliis  i^  rr|iiiiiii|  «i A.ral  Iiiih'-.  iiiiiKiiii: 
Iiarallrl  iiK-i.-imi*  as  widely  aiul  (l<'('|ily  a«  tlu'  (i|ii'ratiir  iii  hi-  jiiiL'- 
imiit  liclicvfs  aihi^alili'  fur  iln-  niu'  npr-al  imi.     it   i--  In -I  in  r\i'i\  lasc 

Inr  thr   -liruciill    nnarrll-liiMlril    til    tlli-    IIKlliml    III    1  aillil'l/al  iiill    In   r"II\- 

iMciu  r  I  aiitioii.-lv  until  cxiifru'iK  T  lirciiim  »  hi  <"iiilr.  It  i-  iint  iii'irs- 
sai'V,  liiiwcvir.  to  limit  tlic  tirst  ii]M'i'aliiiii  In  niir  >ii>il.  linlli  ran  Itr 
Ircjitnl  .It  rarli  -iiliiii^-.  I'hi'  several  (lay-  iiiilil  -prays  ami  liirlil  diet 
will  lie  I'l'ijiiireil,  The  11  I  he  ii|ii  I'al  inii  laii  1  <  re|ieii;iil.  ami  -n  nil  illll  il 
llie  Uiil'k  i-  iliHle.  A.-  a  Illle.  ihlee  iiT  fnhl'  ii|ieiatliili  will  -llllice  fur 
eii|ii|il  'te  reiiiDVal  nf  the  nil'emliiiL:  ti'-iie.  'The  [iilhu's  (if  tile  fame- 
iiMiM  remain  imiii jiireil.  ami  a  -iimntli  tnii.-illai'  .-lump  lie  left  mi  radi 
-nle  as  a  le-iilt.  In  ihe  -iilniieriied  imi-il  a  Mniilar  methml  mav  lie 
I'dllowed.  The  pliia  trianunlaii^  lan  alsn  ninic  readily  he  ieiiin\id  li\ 
elect  fiiiaiitery  than  hy  aii\  nther  niethml:  and  it  i-  aiKmated  -tiniejlv 
liy  i'ynelinii.  with  the  cinr  additinii:  that  he  draw-  mil  the  nll'iiidini; 
ti,->lle  with  a   teliaellllllll  eaell    lime   lielnre  npij'at  i  II'J'. 

in    pi'ifiirniiiii;-  nece--ary  nperalinn-  iipnii   eithif   im-r   nr  thniat. 
it   sliniild   never  lie  the  aim   merely  In  i:i\e  relief.      While  this  i-  un- 

dnllhtrdly    ille    llln-!     illl|inl1ant    nliiect.    the    enrini'tie    eil'eil     -hnllld    alsn 

lie  kept  i'eliuii'ii-l\  ill  View.  W'heii  Nature  ill  her  liiL'he^t  and  iim-t 
nnrmal  develiiiiment  leaves  a  -ymniel  rieal  -iirfaie.  the  -iirucnu  -h.uild 

endeavnr  tn  (In  sn  lilscwi-e.  and  the  lleafi  I'  we  call  fi-tnfe  the  varinu- 
iir,L'Jins  we  have  tn  inat   in  the  iinriiial   fniin  and  I'liiiditinu,  the  inortr 

Slirelv    We    have    lielfnl'mnl    nlll'   dlltV    tn    nlir    patiellt. 


' 


d- 1 

. ,  1. , 

>!  i    i  ' 


(  IIAI'TKU   WAX. 


i..\(  r.\.\i;  inNsii.i.ii  i>. 


n 


Tins  ili.L'asi',  ii.-  ils  iiaiiic  Jiiijilii.-,  i>  ;iii  iniiic  inlliimiiiatioii  of 
ilii'  hiciiiur.  or  cnpl^,  nl'  the  Idii.-il.-.  jillcinli'd  liv  tin.'  tlL'pii>il  of 
u  hit  i.-li-_vcll()W  cxiidiitf  ;it  tlicif  iifiliccs. 

Pathology.  -'I'Ik.'  iinirMil  Ic-ion  cnii.-i-is  of  a  i-aliii  liiiil  iiillaiuma- 
tioii  ol'  the  |iai'riicli_viiKi  nf  the  l(iii.-il,  accdin |iaiiir(l  li_v  a  lilifiiioii.-  (.'.Mi- 
ilation  Jidiii  tlic  liiiiiij;  iiieiiilnaiic  nl'  iho  laciiiiu'.  lilliiiir  tliciii  with 
litth",  ]i('iifly-\vhitc  iiias.-cs  {•()|ii|hisci|  <<(  li'iicocytcs.  lihriiicii.-.  Iil)i'il!;e 
(Siiki'low-ki ),  ami  cjiitlu'lial  ft'lls,  which  apinar  \isiMt'  at  the  n|iriiiii,i,fri 
111'  tlu'  cfviils.  As  Ihcv  iiicfcaso  in  .-i/.c  tlirv  >pft'a(l  mil  (i\rr  tho 
iiiiK  oil'  im'iiil)i'aii(',  siMToiiiKliiiL:  thr  nicniiii.-  nl'  ilu-  laciiiia'.  ami.  hciiii," 
Milt   and   frialik',  arc  t'asily  hiiishcd  auav. 

Iii'^ai'diiii:  till'  ]in.--;iliilit_v  nt'  iiiistaUiiiu  tliis  disfa.-c  I'm'  di|ihtln'i'ia, 
Sciidziak  ill  IMh;  invcstii^atcil  llic  siihjccl  mtv  fully.  In  thirty  ca.-fH 
uliicli  wcrt'  hi.-;lii|i!^ically  cxaiiiiiKd,  all  wric  fduiid  Uw  fri.ni  Klchs- 
Ldi'lllcr  iiacilli:  four  had  Lnrlllrr'>  p.-ciiddiliphtlHTia  liaiilli.  Inil  tlu'y 
ucfi!  nii.xcd  with  dtlirr  |iatli(i,i:eiiic  iicrni.-:  while  all  hail  .-laiihyhn'OL-ci, 
slfcptociicci,  or  |iiu'iiiii(H(>r(i,  cither  siniilc  or  eoiiihined.  sia|iliyloc()cci 
hciii.ii'  usually  in  excess.     His  concliidiiii:  wdrds  are:    - 

"IJelyiiiL;'  on  the  clinical  |iicliii'c  nf  the  di.-ca~c.  and  the  rc-iilts 
ohtaiiied  hy  liaclcrinlnuical  im c.-ti;_Mt ions  in  my  thirty  ca-cs.  1  main- 
tain that  the  so-called  follicular  aii;::iiia.  or.  hetlei".  lacunar  tonsillilis, 
is  elinically  and  hi-lojouically  an  indc|iciidcnt  ]iatlioloiiical  iirncess, 
liavinj:  nothiiiL:  in  cnmnioii  with  true  diphihcria.  It  is  no  diuilil  in- 
fectious, hut   We  tinfort  uiialely  dn  ni.t   know  its  >peeilic  \iius."" 

The  coinnmn  title,  "follii.'iilar  tonsillitis,"  iismilly  applied  to  this 
disease  is  not  only  discarded  hy  Seiid/.iak,  hut  also  hy  W'olfendeii, 
Lennox  Tn'owne,  and  others.  Wolh'iiden  say>:  '"'I'lic  \(iy  term  •fol- 
licular" is  really  erroiieoiis,  since  it  is  not  the  fojli.  h>  of  llic  tuiisils 
wlii(di  are  aU'ectcd,  e\i-ept  in  a  very  secondary  I'laiiiier  and  in  a  ir\v 
ca^os.  It  is  the  ton.-illar  crypts,  or  laciime.  which  aie  the  chief  seal  of 
the  disca.-e." 

As  a  mil',  liotii  tonsils  are  atl'eeicd  >iiiiulianeoiisly.  The  calar- 
riial  aireetion  extends  to  the  pillars,  palate,  and  pharynx  also,  and  no- 


(»i!(i-riiAi!VN  \.     i.AcrsArt   rossit  i.i  ris. 


':;< 


Ins 

',,1- 
lils 

lot' 

l"~ 

lu'- 


casionally  spots  df  cxiKlatitiii  (uriir  nii  ilic.-c  pari-.  'I'lir  ctrvical 
{rlands  liKi'wi.-i'  liccdinc  sensitive  ami   in  mimic  cases  eiilar.ireil. 

Etiology.  It  is  litiierally  lidievcd  to  I'c  a  speeilic  disease,  de- 
peiulciu  upon  the  access  of  iiiiero-org'aiiisiii-  to  the  toiisiN  in  certain 
condition-  o]'  the  sv.-tcni.  \\  liMc  in  <oine  I'c-pccts  it  rcscndilc-  the  ex- 
antlicinala.  it  dilVci-  fi'iini  ihciii  m  lieiiii:  in  no  \\;\\  ]irolccti\c  uiiainst 
th(>  po>-ihilit_v  ol'  I'iiiui'c  attacks. 

Allhonjih  the  irciin  itsdf  and  its  oriirin  art  .-till  unknown,  it  is 
lielievi'd  rrcipiciitlv  to  ai'ise  I'l'imi  the  cU'incnts  o**  putrefaction  m  de- 
fecli\e  scwcis  'I'hi-  idi  a  ha-  oriLiiiialcd  fidin  ilic  fact  <d'  it-  preva- 
h'liee  in  old  houses  where  drainaiic  has  hcen  ilcfcetive. 

Scn.-itive  inllanied  throats  with  ciilarLied  tonsils  arc  fit  sidijects 
for  inl'eetion.  'I'lie  spoiiLiy  ti->uc  with  open  civpts  olVer  frei;  lodL^inetit 
for  llie  invadinir  hacteria;  and.  as  a  similar  tonsillar  hypertrophy  fre- 
(piently  all'ei-t-  all  lh(>  children  (d'  ;;  family,  all  may  he  alTccted  sue- 
<-essively  hy  the  endemic  infection. 

Altl'oni:li  more  pre\aleid  in  ehildhiMiil  than  in  maturcr  yiar-. 
it  frequently  occurs  durim^  ih"  latter  pci'jnd.  Sex  lias  no  sjjec  ial  in- 
tluence  over  it.  .\-  miL:ht  lie  I'xpccted.  ji  is  more  prevalent  in  the 
spriiiiT  and  fall  than  dnrinir  other  seasons  (d'  the  year. 

One  pcciiliar  fcalui'e  that  las  hcen  (ihscrve(l  hy  rhinoloL,dsts  is 
the  developincid  of  lacunar  tonsilliti-  in  fi'oin  twcnty-fnur  to  forty- 
eij:lit  hours  after  nasal  operation,  particularly  when  jterformed  hy 
<ralvanocautery.  The  tluMiry  has  been  ailvanied  that  the  absorption 
of  the  ".'erni  iniirht  take  plaeo  Ihrnnufh  the  nasal  wound,  and  the  near 
proxinnty  {>•>  the  tonsils  would  facilitate  its  tran-itioii  and  the  de- 
velopinoTit  of  lacun.'ir  di-(  a-c. 

If  the  disease  occurred  cipially  after  knife  and  saw  n])('rafions,  llic 
theory  woidd  ser'ni  more  t'ea>ihh'.  .\s  ihe  L'alvano<aidery.  when  it 
docs  not  produce  ha'morrhai:e.  hcrmeiical  seals  the  wound,  may  it 
lud  arise  from  the  i'aet  that  Lrahaiiocautei'y  o|ierations  u[)on  the  nose 
are  ti'mporarily  fidhuved  hy  ledi  nia  and  more  or  les.s  stenniais,  resulf- 
inir  in  Tnoutli-lireathin;:?  The  impact  of  the  ,i:erins  npon  the  crypts 
durini:  ihe  depressed  vitality  rcsultinir  from  the  shock  of  op(Talion 
would  I'aturally  tend  to  inflammatory  action  in  the  nriran  so  affected. 

Symptomatology. — The  onset  of  the  disease^  is  luded  hy  a  irem  ral 
fe(din,ir  of  chilliness,  which  may  last  for  several  Imurs,  to  he  followed 
by  fcbriie  action,  the  temperature  in  smne  cases  risin.cf  as  mii(di  as 
thrcn  or  four  de^'reos.  Tain  in  the  back  usually  accompanies  the 
dcvc'lopihcnt  of  fever.     ']'o<rether  with  the  fever  and  \K\\n.  the  throat 


¥ 


:      ii 


DISK  \>i:s  (»|-   iiii;   niAHYNX. 


-yiiijilniiis  luiiiiil'i'st   tliciii~(  Ives.     'I'lii'ic  i- 


li'Viicss  iiiiil   irritntiiiii.  ful- 


II'  . ! 


li)\\i'(l  hy  the  rnriiiiit  idii  111'  ihc  lacimai'  ili-pn.-ii,  acroiiiiniiiii'il  liv  |iiiin. 
upon  iiiovciiiciil  ul  llic  iDiisils.  pjirtu'iihirly  in  doulntilidii.  In  yniuiji 
I'liiMicn  tlir  sv.-tcinic  disiuiliancc  i.-  soniclinic*  vitv  severe,  the  leni- 


lei'aliire  n.-mii'.  even  tliiiiiL:li   rai'elv,  a.-  Iii'jh  a.- 


in; 


ami   u-hei'eii   m 


IV  eiin\  ul-iiiii.- 


Wilh  the 


1i1l:Ii    teni|iii-al  lll'e   tllel'e   will   lie  aceelel'a  I  ion 


nf  |piil~e  and  al.-n  III'  re-|iir;uiiin. 

r>y  the  .-eennd  or  third  (hiy  the   I'elnih'  syniptoni.-  .-uliside,  an 


inii'.-iie  a   veiv   inndilied  enui'.-e   iinlii   the  ilisea-e  ihsapipea 


r~.    hetweeii 

II K'  lil  t  li  iind  M'veiilh  (hi  v.-  I'lnni  il>  eoninieU'enient .  The  i  hfnal  .-\  n!]i- 
Iunl^  |iei'si.-t  until  near  ihi  ejnse  oT  the  ailaek,  uide»  nioditied  hy 
t  real  nienl. 

In  .~e\eie  ease-:  idliuiui u u fill  i>  luiI  hv  ally  ineaii-  a  liiie  -ymp- 
luin.  rnrnieily  ihi'  presence  i>\'  thi-  eoiiiplieiilioii,  in  e\udali\e  throiil 
dis(■a^e  ol'  any  l\iiiil,  \va>  enii.-uh fed  a  po.-itive  iiidieatinn  that  the 
diseaM'  was  diphtheril  le.  'riii>  idea  is  imw  discarded,  and.  ahhuuu'h 
alhiiiniiini  ia  is  ninre  prevah'iit  in  diphtheria,  the  mily  pn-ilixc  e\i- 
ileiice  niiw  ackimw  h'diied  111  I'aNnr  ol'  that  di>caM'  is  llic  presence  of 
the  l\h'h,«-Li)elller  hacillir-.  In  regard  In  allinniinuria,  W'nlt'enden 
.-late.-  positively:  '"That  it  i<  rarely  ali-eip  in  ca.-e>  ol'  acute  |on- 
silliti.-." 

I'lieuinonia  and  ncphiiti>  have  .-npi  r\incd  in  rare  instances, 
while  orchitis  and  ciilar.ued  >pleen  are  oecnrrciicc-  widch  have  heeii 
known   lo  iniincdiately  follow  the  tonsillar  disease. 

Diagnosis.  -The  only  other  di.-easo  it  is  liktdy  lo  he  confounded 
wilh  is  diphtheiia.  Siuiic  ea>es  may  .-o  re-einhle  mild  diphi  lierit  ie 
di.-easc  thai  in  -iiiiple  clinical  e.\aiiiiniU  ion  an  ciini'  in  diauiiosi-  miiilil 
occur,  and.  in  fad.  has  freipieiitly  lieen  made. 

To  examine  the  faiice-  i horiuiiihly.  lellciicd  li.uht.  head-mirror, 
and  loiiuiie-depressor  are  all  nccc--ary.  In  lacunar  tonsillitis  the 
::land  i>  red  and  swollen,  while,  ai  the  mniilli.-  u\'  ihe  lacuna',  clear, 
white,  pearly  spots  will  he  seen,  adliei'in.t;'  closely  to  tlie  miii'ous  nicin- 
ipiMiie  heiieath  'J'hese  spots,  as  they  (K'Velop.  u'l'ow  smiiewhat  larizer 
and  extend  outwardly  around  the  iiioutlis  of  the  crypts,  and  can  lie 
hnislu'd  oil"  with  the  cotton-holder  without  injuriiiii-  the  surface. 
They  always  retain  their  original  cohu'  id'  hlui.-h  or  yellowish  white 
and  are  non-odorous. 

In  diphllioria  the  tonsil,  alflnnmh  siunewliat  swollen,  instead  of 
beinir  hri^zlit  n^l  is  id'  a  bluish,  tur.udd  color.  The  exudation  fonn.s 
an  even  Hake,  varvinir  in  tliiekiu'ss  ami  covorin<i  the  tonsil.     In  color 


It 


nli(»-|'ll  AliVNX.       I.AClNAIi     I'ONSI  1,1.1  )!>. 


1 .» 


I'liir. 

rlir, 

'111- 

IICI'. 

lit.; 


|ins 
llor 


it  is  yellow  nr  ".cllnw  i>li  i;ray,  juhI  ciiiiiiot  In-  lini-linl  nil'  uiiliniu 
Iciivinir  a  raw  >iiriii(('  liciuiiili.  (>ii  tlic  sccmid  or  ihiid  ilny  iii-tcaij  of 
I'ftaiiiiiii:'  its  color,  ihc  iiiari:iii>  a--iiiiic  a  j.Tayi-li-iilack  tiiii:<'.  aiui 
iiiiilodor  i>  (li>tiiictly  |M'rcciiiilili\ 

<liic  other  |ioiiil  ill  eliiiieal  lii>tory  is  of  eoiisideralile  iiiiportaiiee: 
Aeiile  lacunar  tonsillitis  is  a  sllieiiic  diseiist-  with  lii<:li  ''elirile  action, 
w  liena-  diplu  licria.  the  iiiavr  di.-ea>e  of  the  two.  i-  asthenic  and 
marked  liy  i  lower  teiiiiicral  lire.  Ilotli  are  infection.-.  Init  di|ililhci'ia 
is  the  more  virulent  id'  the  two.  Still,  in  all  ea^cs.  where  there  is  tlie 
siij,dite>t  dmiht  ill  dia-^iiosi^  it  i>  hetter  to  -uhiiiil  the  exude  to  iniero- 
seopieal  evamiiiatioii.  The  hi-Ioiy  of  the  ca>e  slnuild  di.-tiii,LMii>li  it 
from  the  throat  crn|itioii  of  the  exantheiiiatoiis  (lisea>.'s.  also  fniiii 
cancer  and   ,-yphilis. 

Prognosis.  Thi^  is  usually  favoralde.  The  di-eaM'  runs  a  re'_Milar 
(oiirse  of  four  oi'  ti\e  ilay>  ny  a  week.  and.  altlnuiLdi  it  may  he  attended 
hy  considerahle  pain  and  fever,  it  is  not  likely  to  leave  any  -crioii- 
cDniplicalion  altci'  it  -uhsides.  The  alhiiniiiinria  which  occurs  :>; 
usually  mild  and  of  >lioil  duration,  i'araly.-i-  (d'  the  pah.li'  ha-  in  a 
few  instances  fidlowcd  the  disease.  Ia>tint;'  at  the  |oni;cst  only  a  few 
wi'cks.  (,)uin.-y  has  ,d^o  heen  developed  as  a  re>i;lt  of  the  tonsillar 
irritation. 

Treatment,  .\ticiition  to  hyiiieiiie  rules,  aluindaiice  (d'  liuhi  did. 
and  regulation  of  the  alimentary  canal  are  all  that  seem  to  he  re- 
t|nired  in  many  of  lhe,-e  cases.  While  the  fever  i-  hiuh  and  the  tiowcls 
eoiisti|iated.  >aliiie  e.itliartics  ai'c  indicated.  I'pon  the  hot  and  irri- 
taiile  throat  alkaline  spiays  hav(^  a  LM'atcful  elVecl.  .\moni:  the  in- 
ternal rein('<lies  none  liaxc  a  hetter  repiita'ion  than  tr.  fi'r.  iiiur.,  ".'n 
per  cent,  ill  iilycerin.  in  doses  (d'  I  to  '■.'  Lirammes  every  one  or  two 
hours.  It  is  liivcn  iimliluted.  it-  cllicacy  as  a  sv-temic  tonic  heiiii: 
allied   hy  the  direct   contact   of  the  iron   upon   the  ton-illar  exudation. 

In  my  own  ca-es  I  have  not  admini-lered  the  iron  in  this  wav.  Init 
ha\i'  diliiti'd  it  Very  freely,  in  ordei'  lo  a\oid  any  injurioii-  ell'cci  the 
clihu'ic  acid  iniLiht  ha\e  upon  the  teeth  id'  the  patient.  To  free  the 
tonsils  the  ferric  ;^lyiei-ide  was  applied  twice  a  day  to  thciii  hy  nnaii- 
of  a  cotton-holder. 

In  many  of  tlie-c  ca-es  I  ha\e  <cen  ailvanta;.''e  from  the  -edative 
and  a-trim.:ent  ell'ect  of  nitrate  of  silver,  applied  in  the  oarlv  >taL'e  of 
eMidatioii.  The  tonsil-  were  lii-t  hrii-hcd  with  a  l-per-ceiit.  solution 
of  cocaine,  followcil  in  three  or  four  minutes  hy  the  application  of  a 
10-per-ceiit.  -olulioii   of  the   nitrate,      l-'or  the   liist    lioiii'   the   patient 

1T.( 


i::|:     •, 


'wr- 

\    1 

1. 

2?6 


iiisi:asi:s  ok  iiii;  i'Iiauvnx. 


wciiili]  sc'irccly  iHTccivc  iiiiy  clVi'd  I'nuii  llii.'  ;iit|iliiMliiiii.  'I'licii  llic 
scii.-alioii  III'  .-(irfiii.-s  uoiild  luilv  \)v  ?li:.'lil.  I'>_v  llu'  fnllowiiiL;  day  llio 
flopu.^il  WdiiM  lie  more  tliaii  hall'  ol'  it  ynm;  ami  a  .-cioiid  similar 
iri'aliiiciil  would  t;()ii)|)lc'li'  llif  rctiinval.  'i'lic  diliucd  iruii  soliilion 
wuuld  lie  I'ciiiilarly  adiiiiiii.-l»'n'd  iiitciiially,  during'  tlic  wIkiU'  pi-riotl 
ol'  trt'atinciit ;  and,  liy  the  (•(Hidiiiicd  inctliods,  t!ir  tiuir.-L'  oi'  tln'  dis- 
mast' Wduld.  ill   mail)    iti>laii(  t'.-,  lie  iiialcrially  .-Imrlfiicd. 

1  liavi'  I'liiiiid  till'  iiiiralc  ol'  .-ilver  particularly  u-i'l'iil  ii;  lliat 
traumatic  class  of  cases,  the  result  of  nasal  (i|iciatiou>,  already  re- 
ferred to,  tjiiite  frequently  only  a  siii;:le  bru^hiii;!  willi  tlu'  silver  iieiiiL' 
required. 

When  there  i>  much  headache  and  iii-nmnia  '  ^-  to  ',  _,-gramnie 
doses  of  iiheiietidin  or  acetanilid,  ,i;ivcii  at  lied-tinie,  will  often  secure 
ijuiet  and  refreshing  rest  for  the  night;  ,-nialler  doses  to  ho  given  to 
children  in  proportion  to  age.  id'  this  as  well  as  any  other  medicines 
rctjiiired. 

If  there  IS  much  diprc>-ion  alter  the  lir>t  two  or  three  dayr-, 
iiuinine  may  hi'  reMUled  lo.  in  '  \,-graiumc  doses  once  or  twice  a  day. 

The  (|iiestion  of  iMilalion  in  lacunar  ion,-illitis  is  one  of  no  little 
iiinnient.  \Vlicue\er  there  i.-  the  ,-lmhler-l  dniilil  a~  to  the  ideiiiity  of 
the  disease,  there  >hould  he  no  hesitation  upon  ihc  matter,  and  Mic 
patient  should  at  oiicc  he  placed  out  of  re;ich  of  alfeciing  oilier,-. 
When   .sure  that    \\  e  have    iioi   diiiliiheiia   to  contend   with,   we   mav 


'Oinowhat   relax   our  viiiils.  while  care  is  taken   l^ 


I   kee|i   the   |iaiient 


aloof  from  tlmse  who  would  he  most  susi-eptihic  to  tli 
inji  tlia!  the  chief  daiii:er  is  from  its  ei 


c  ili-ca.-e.  Know- 


idemie  eliaiacler.  and  m  t   I  I'om 


IO,-lI 


the  slighlly-infectious  nature  of  the  e\udation-de] 

In  Ireatnieiit  of  aciile  lacunar  tonsillitis  I  do  not  think  the  lance 
oan  evir  he  iei|uircd.  .\ftcr  the  subsidence  ni  the  disi'ase,  however. 
if  the  loii.-ils  are  hy|uil  lophiid,  ionsilloioniy  should  hi'  perfoiiued. 
This,  in  a  large  measure,  would  pri'Veiit  the  recurrence  of  the  disease. 

As  an  external  applicaticui,  camplioiateil  oil.  or  a  (N>ml)ination 
of  spirit  itf  lurpeiiline  and  olive-oil.  rulihed  over  the  region  of  the 
tonsils,  and  the  surface  eover^'d  at  once  with  a  layer  of  absorbent 
eottnn,  alwavs  aiHwers  a  Li'ood  iiurpose. 


I  iiArri.i;  i, 

I'll  \i;NN(ii;.\i.  .\!V(  (ISIS. 

M^|(l-!v  I'liiii^niilcs,  a  ciiiiii.iirnl  i\  I'lv  rare  di.-ca.-r,  \\ii(ii  ii  dncs 
(icciir  ii.-iiallv  iilVrc!.-  Miiiit.  |Hii'tiiiii  nf  \\\f  j'aiii-f.-.  It  is  Irriiicd  ■"myco- 
cis  iiliaiviiLicii-."  ■■in_vc(i-is  ti'ii>illai'is,"  "iiivcu.-is  liiiiriiiilis,""  cic.  ac- 
ciii'iliii::'  til  ilir  iiiiiiiiiis  iiicmliniiic  alTidtil.  lint  iis  it  cnIi'IuN.  in  iiidsI 
instance-.  t(i  all  iIm-c  localities,  liciiiix  raifly  coiifimMl  exdusivrlv  tn 
diU'  ^itl'.  tlio  title  iit  the  head  t'l'  tlii>  <  halter  may  he  ccn-idered  ;he 
hc'^t  (Fii:.  S:^). 


*■   -1;    L\ 


laiH-e 
,ever. 
llied. 
-e:\se. 
lation 
tlio 
Irltcnt 


l-'iir.  ^'i.      IMkii  \  iiLr"iii\  cnsis.     lAutiinr'^  -pciinu'n  li\   W'lincli.i 

Pathology.  -The  lorni  mycosis.  I'mni  the  (ireek  wmd  iivx-r-.  i-\g- 
nifyiiiiT  I'lmiiii,-.  indicates  the  character  of  the  plant.  This  is  a  ])ara- 
sitic  disease,  c(iin|iii-.ed  oi  small.  '.\  hili.-h-ycllnw  liniuihs.  dense  in 
.strucMire.  and  pnijcciiiiLr  aliove  the  ninciMis  niemhrane  upnn  which 
they  have  urnwn.  It  helon^'s  to  the  schiznniyccles  ::i(iiip  of  t'un;:i:  and 
the  species  i.-  called  leptothrix,  from  the  cyliiidrii'al.  or  throml-liko, 
shn[H'  (d"  the  cells.  'I'hc  term  is  aiijilicd  to  a  variety  (d"  veirctahle 
(tr<:anisms  I'onnd  in  drains.  :.Mrl)a<re,  Imtrs,  etc.  Thev  mav  also  he 
found  in  milk.  mine,  and  fold  watery  solutions,  after  proloiijjed  ex- 
posure to  the  air.  The  inicmscope  reveals  the  thread,  ov  ro(ldikc. 
cells  (if  the  lepidihriv  indieddcd  in  anMi-phnu-  Lrrannles.  streptococci. 


t'  f  I 


•i 


i 


-~*t 


278 


DISKASKS    or    Tin:    niAItVNX. 


etc.  (Fijrs.  Ml  iiml  N")).     If  trciilcd  uitli   liii<:(»rs  solution,  these  Itodie? 
assume  ii  liliii>li  tiii<:i',  iiidieatiiii:  tlie  presence  of  >tiir<'li.     Tlie  cell- 


1    :  I. 


i         ,1 


V\<^.  S4.     I.«'|)l(itlirix.     Advfiititiuus  follicle  to  left    «itli' 
(  Author"-;  siiccimcii  liy  IJt'iislcy.i 


I  ! 

i 

t  * 
1 


Fig.  8,").     l.('|itolliri\   /;(  xlin    i'  ,  iiicli   nliicctivci. 
(After   I^cniiox    lirownci 


I 


vary  in  form  iieeoi-dinix  to  tlie  iiiiatoniical  reirion  from  wliicli  tliey  are 
removed.     When   the   fiin!.nis  aiipears  on  the  surface  (d'  tlie  mucous 


arc 


»i 


OUO-I'IIAUVNX.       I'llAItVNdKAI.    MY(()SIS. 


-.';!• 


iiu'iiiliriiiic.  it  iiiiiv  he  |uirfly  >ii|i('iliciiil.  or  lir  iiisritcd  in  a  wcil;.'!'- 
flui|U'(|  iiiaiiiiiT  ill  the  parciHliviiia.  In  llic  (Uir  it  i-  r-iinply  attaclMMl 
/■;/  iinixsi'  tn  tile  llatlciicd  cpit licliiiin.  and  i-  Iiii|ii<il;i'iiciiii-1_v  slriatcd 
in  a|i|it'araiur  (  Uosudrtli ).  In  the  dlliiT,  when  ii  iiiiicii'alcs  dci'|ily 
into  tlu'  I'liitlii'liiiiii,  tilt'  ;,fni\vtli  is  dciistT  and  iiinic  ;:ranular,  ;iiid 
till'  iiiicroscn|ii'  MiinctiiiU'S  fails  to  dciiiiiii.--trati'  the  iMd-likc  I'dls. 
Ilt'rvii>i-  liflicvc-  that  this  nlditfinl  inn  i>  caii-fd  hy  the  |iic.->i:r('. 
Wlu'ii  the  iiiycd.-is  ciitfrs  still  dt'(|irr  inln  the  (ry|it.-.  the  latter  lic- 
coiiu'  dilated  and  Idled  with  l'iiii^n)ii>  LMowtli,  deireiierated  epilheliiiin, 
and  aiii(ir|)li(iii>  matter.     Sninetiine,-  ;i   horny  hypertrophy  of  the  ejii- 


\ 


V\)l.    SCi      Kfiiild 


111    toii-ij    with    |(|piiitliri\    i'   .iiuli    nliji'ii  i\  r  i . 
(Alter   l.ciinnx    Itriiwiit'.) 


tlieliMl  celU.  instead  of  -iiiiple  catarrh  of  ihe  irypi-.  aet^  a~  a  liase  for 
the  leptotlii'ix.  foriiiiii;:'  a   keratosis  of  the  loii-d  (  l-'iu.  •'^I')- 

Etiology. — The  oi'i.iiinal  >oiiree  of  ihe  fiiimii-  i<  -till  a  matter 
of  (|iiestion.  The  miei'o.-copieal  examination-  of  Toepliiz.  W'auner. 
I  hiniaseliino.  Colin,  and  others  have  proved,  hdwcvri'.  that  the  li'|i|o- 
(hrix  is  frecpieiilly  found  in  the  month,  ahidiiiu  there,  like  man\ 
other  licrms,  iiin(uiioii>ly.  hut  that  a  eoiidiliim  of  impaii'ed  heaitli. 
t()j;i'tlier  with  idin>ynerasy  (d'  const  itiit  ion.  W(mld  appear  to  he  le- 
i|tiired  to  sectiro  the  attachment  and  niowth  ol  the  fimuus  within 
the  pharynx.  Tiic  peculiar  featiii'c  i.-  that,  althoiii^h  the  hacteria  may 
he  present  in  such  laru-e  iinmhers  uiihin  the  iumI  cavity,  they  should 
.so  rarely   liiid  a  nidus  fo|-  dcvelopmciii   then',  and   -hould    prefer  the 


:|| 


■ 


w 


■\\ 


\ 


M 


I 


K' 


;  r  ;   t 


j,i  n 


*1 


Sfhd 


nisi;.\si;s  (U    i  in;   ni  \  i:v\\. 


.i>: 


li 


{  1 


: 


tf-^iN 


li    I 


iM 


fiiiiciiil  ii';:i(in.  I'i'i  li;i|i.-  tlic  inlciiM'  inii-culiir  ;iiii\ily  nf  iIh'  mMiiili 
il.-r|r  iiiny  ad  as  a  ildi'iii'in  to  Icjildlhrix  aUachiiicnt.  Sex  ha-;  liltlr. 
if  anv.  inlliii'iirc.  It  rai'civ  dcciir-  licruro  early  iiialiiiitx.  and  imt 
vci'V  nfifii  ill  did  aL;c.  ('nliii  .-ays  tin'  prridd  dI'  lil'i'  lia!>lr  Id  allack-; 
is  liciurcii  ilif  aiics  (d'  tjii  and  lid  year-. 

Sicliriiiiiaiiii  (Aniiir  fiir  Ldri/iiiiiiliniir  nihl  l!liini)i()(jii\  \^\)'i)  lia- 
a  IdiiL:'  ariirjc  iijiiiii  tliis  viilijcci.  (  hi  !ii>ld|d-ifal  LiTdiiiiil-  lir  >trdimly 
comhats  llu'  tlicdiy  ijiai  )iliaryiiL:di!iycdsis  nwc-  iis  drii.fiti  id  ihc  pres- 
ence (d'  the  leptdl  liriv.  Ill'  (Ir-I  de.-erilies  the  iiiieidscdpical  appearaiiee 
df  a  siiiL^le  (|iiil|  of  ilie  di-ea-e  and  llieii  a  -I'didH  (d'  the  tdii-i|  with 
(|iiill  (//  silii.  'Ihr  eMiniinatidii  >h<iu>  the  ina.~-  Id  he  made  up  of  a 
eysl,  (ir  saek,  cdinpdMil  d|'  a  central  nai'mw  liiinen  .-iirrdiii  ded  h\'  an 
epithelial  wall,  lie  c(nii|iai(>  it  wiili  the  hiinian  hair  in  ~iriieliire. 
'Che  wall  (d'  the  i|iiill  is  partially  Cdnipd>ed  d|  haiihued  iinniieleated 
epitlndi.il  cell-,  and  partially  id'  hdnid,t:'eiiedii>  lidinv  >iih>taiiee.  'The 
central  Iniiien  i-  naridw  and  lilled  with  drlriliis.  haeieria.  and  iniieu>. 
'{"he  iiiiler  siirfaee  <d'  the  (jiiili  as  it  (U'djeets  i'mni  the  erypi  i-;  ed\ered 
willi  hiiiulles  id'  leplnlhrix.  lie  >ay.-  that  in  the  iieiLihlidrhddd  id'  the 
ery])i  lh('r(>  is  no  evidence  of  inllannnatidii.  siudi  a.-  hypeiti'dphy  of  cuii- 
iicetive  tissne  and  small,  nnind-eidled  inliltratidn. 

As  the  resnil  id'  his  invest  iu'at  ions  he  cdiuliide-  that  the  pmees^ 
is  an  iinnsnally  intense  ciirnilieatidii  ni'  the  lacunar  epithelium,  ternii- 
naliii.ii'  in  ipiill-I'drmatidn.  lie  alsn  says  that  l<crald>i-  nf  the  tiuisil- 
cryjils  in  a  mild  fniin  is  not  an  nncdinnidii  cdiidilidii.  and  that  the 
pri'scnce  id'  the  leptnthrix  is  pnndy  incidental,  and  hear.-  mi  relatinii  ti> 
the  dis(  ase  a-  a  eansat  i  ve  factiir. 

'I'lie  I .('jil'illi ri.r  hiiniilis  is  a  ^apniphyte.  nr  I'linuiis.  I'liuiul  in  almd>t 
every  nidiith-  -the  nidic  richly  where  the  epilhelial  cells  are  lliicke-.t. 
liasini:'  this  theory  on  the  ahstdiite  deimmstration  of  llie  ejiithelia! 
rofmatidii  of  the  iniills.  with  the  manifestation  of  the  leptdtlirix-s])ores 
only  on  the  outer  surfaces.  Siehenmann  considors  1ii>  case  dearly  dem- 
onstrated, and  desires  the  name  of  the  condition  to  he  diaiiLicd  to  that 
of  ''Hyperkeratosis  I  aciinaiia." 

K'icliardsoii.  of  W'a-hinirtoii.  from  iiatliolo.i^ical  examinalion  and 
I  linica]  experience.  alMi  stronirly  favors  Sielienniann"s  \  iew. 

The  a^es  of  all  the  ease?  1  have  seen  arc  the  fidhiwiii;:-:  IT,  ii>. 
'■i'2,  2n.  '^>8,  :!(),  40,  T).").  and  (iO  years.  The  la.-t  two  occurred  in  the 
same  acntlcman,  with  an  interval  of  lictweeii  four  and  five  years  of 
(Mitirc  freedom  from  the  disease.  The  second  ca-e  was  that  of  a 
<rirl  \vnrl<!nir  in  a  hrush  fadorv.     She  stated  that  the  dust  from  a  cer- 


II' 


i 


1>I 


oKM-rii AUVNX.     i'ii.\i;v.Nt;i;.\i-  mV(()si>. 


•J  SI 


fain  kind  of  hristlfs  ahvavs  produced  sori'Jic>:.>J  of  the  tliroal.  wliii  li 
eVL'nuiaiiy  di'Vclojiod  into  this  disease.  Tlie  sixiii  ia>e  is  also  uorlliy 
(d'  incMliiiii.  'I'lie  patient  was  a  yonni;  farmer.  Two  _\ears  Ixl'ore  I 
saw  iiiiii  with  tile  ni_vci)-;i.H  lie  came  from  a  dislaiit  tnwii  to  lie  irt'Utid 
I'nr  aiilial  dJM'ase.  Alter  .xuiic  weeks"  ireainient  a  r(iiii|iletc  riiic  was 
accompli.-lieii  and  lie  retiirmd  lionn'.  "nc  yiai'  and  a  halt  lairr  he 
.-|)cnt  the  winter  polisIiin,ir  cow-horns,  during'  which  time  his  ilu'iat 
hecame  sm'e.  in  the  spring'  he  came  ajiain  for  trcatniint.  ^Ui  c.aiiii- 
natiiiii  I  found  the  whole  of  the  tonsils,  lower  pharvnjjeal  wall,  and 
hase  of  the  tongue  cdvercd  witii  ihe  leptntlirix  fiin,i:i.  There  was  no 
return  whatever  (d'  the  antral  disease.  Jn  llio  tiftli  case  the  lii-t  indi- 
cations oecnrred  duriiii,''  the  fnurtli  we('k  of  an  attai  k  of  tvplmid 
fever. 

Symptomatology.-  When  .-iluated  in  any  pi>riioii  of  the  i'aiices, 
mycosis  presents  very  few  .'-uhjective  symjitoms.  It  pinduces  no  in- 
llammatory  action,  and  is  cau.-ative  of  slilfne.-s  nmre  than  xireiicss. 
W  lien  the  eruption  is  very  abundant,  a  feelinji  of  irritation  may.  how- 
ever be  developed.  As  the  ]tlants  increase  in  niimlier,  and  liecomo 
scattci'ed  over  a  laiger  area,  the  movements  (d"  the  iliarynx  become 
somewhat  restrained,  and  the  muscles  sli^ditly  .-lilfencd,  partial 
dyspliauia  beinj:  the  result.  Occasionally,  too,  a  >li,<;hl  irritable  cdiiuli 
may  be  jiniiluced;    l)ut  these  pynijitoms  are  never  marked. 

The  miifit  frc(|ueid  .-ite.  and  where  it  present.-  llw  lariic-t  de- 
\elnpiiiciit,  is  in  and  hetweeri  the  crypts  of  the  faucial  ton-ils.  next 
or,  the  liiieiial  tonsil,  on  the  walls  of  the  phaiyiix.  and  last  upon  ihe 
pharyngeal  tojisil  itself.  Siebeiimann  and  Schubert  both  recite  <a.-es 
in  the  latter  reiiion;  but  the  rrrowlli  in  these  was  aspcririllus  instcail 
of  IcjUothrix.  I  have  only  seen  one  ca>e  of  (b'velojmient  in  the  naso- 
pharynx, and  that  was  an  exteii.-ion  upward  fn.'m  the  faucial  region. 

^Mycosis,  when  examined,  presents  small,  milk-white  opatjue 
nia.«ses  ])rojeeting  above  the  mucins  membrane.  They  are  soft  and 
moist  in  appearance,  but  are  not  easily  moveil.  Colin  describes  three 
forms  of  develo]iment :  1.  Small  isolated  s|iots.  '<i.  Larger  spots  like 
a  cock's  cond).  'A.  ."^mall.  smoiith,  yellow-white  jilivjucft.  Whatever 
form  they  take  or  wherever  they  are  loeateil.  |iarticiilarly  in  the  kera- 
tosic  variety,  they  vvill  stand  a  large  amount  of  friction  withont  sepa- 
rating their  attachment.  I'snally  a  large  nnniber  of  the  plant.s  are 
scattered  over  the  area  affected,  varying  in  .size  from  a  millet-seed 
to  a  shelled  cat-seed  or  larger.  Sometimes  they  exist  for  years,  pre- 
senting few  symptnins  of  a  distressing  character. 


U: 


:i- !  I 
li:  ;  ! 


,!l! 


ti  :   it; 


>'MV 


DisKAsr.s  (»i    iiii:  niAiivvN. 


J' 

I 


nil 


Diagnosis.  On  ii  i'ii>iiiil  iiis|ii'i  limi  u  iniL'lit  |M>>-ilily  lir  inistiikoii 
fill'  ili|ililli(  ria:  Itiil  a  ciU'criil  cMiiiiiiiiilinn  -liniilil  at  nncr  rciiuivc 
ilmilii    ill  )lii.>  (lin'('tii)ii. 

Till'  (inly  disease  In  wliiiji  |iliarviiL!(  al  iiiyci-ir  hears  any  rcxiii- 
lilaiire  i<  laciiiiai'  |nii>illilis.  imt  in  <li»l  iiejni-lnni:  it  tlierc  ^liniiM  lie 
iMi  ililliciilty.  'I'lie  (iiic  i-  a  silieiiic  inllaniiiialniy  ili-ea>e  <il'  liniited 
(liiralinii:  the  ntlier.  iiiin-inllaniiiiatnry.  a-tlienic  and  e.».-eiilially 
chronic.  In  the  (Uie  the  cryptal  de|io>it  is  sdl'i  and  |iiiltaeeiiii.«  and 
easily  reiiuiveil.  In  the  other  the  (inn  le|itiitlirix  deve|ii|iiiient  adliere- 
teiiaciMii.-ly  to  any  |iarl  (if  the  |nii>i|  nr  |iliaiyii\  ii|iiin  wliieli  it  iii.iy 
have   uiduii. 

I'd.-silily.  tun.  that  clifonic  eonditinn  n|'  the  tiin>il  in  which 
cheoy  de|in>its  jdiin  williiii  the  laciiiKc  and  |iriitriide  almve  llie  sur- 
face nii;:lit  he  mistaken  Inr  inycnsis.  Here  Imtli  the  diseases  are 
chniiiic  and  niin-inillaniniatniy ;  hut  tliechei^y  iiias-e>  only  apiiear  at 
the  iiKiiith  (if  the  cry|its.  never  anywhere  (d>e:  and  they  are  easily 
pressed  niit,  while  the  inycosis  is  scattered  in  every  directidii  and  (an- 
llot    lie    sd    easily    iiKived. 

Prognosis. —  In  |iliaryii,i:cal  niycdsi,-  there  i-  iidthiiiL,'  (iaiiiicrdiis  to 
life:  and  a  niinilicr  (if  cases,  after  existiiiL'  f'lr  year>.  have  heeii  known 
to  disappear  spontaneoii.-ly.  without  trcatnient.  It  is  only  in  excep- 
tional ca-t>  that  the  disease  is  very  distre.-sinj.';  still,  as  a  rule,  it  is 
interininalile  in  cdntiiiiiity,  and  if  left  td  itself  nii.Ldit  last  thfoiiLdiout 
a  life-time.  'I'liis  Ion;,''  i-onliniiaiicc  nndoiihtcdly  has  a  depressing; 
elVect  upon  the  vital  fdrces,  and  tuay  render  the  .-iilijcct  more  -ns- 
ceptihle   td   the   inlliiciice  of   other  disi'ases. 

Treatment. — The  trcatnient  coiisi>ts  in  the  -eradication  of  the 
plant.  In  a  few  recorded  cases  this  has  heen  done  witli  facility;  hut. 
in  the  majority,  careful,  viirorotis,  and  persistent  treatment  has  heen 
rcijiiircd  for  a  proloiiL^'d  period  lud'ore  cdinplcte  cure  has  lieeii  oh- 
tained.  Tiiicliire  (d'  iddine.  tannic  acid,  nitiaie  (d'  silver,  solution  of 
hiclijdride.  calomel  in>iiniatidiis,  have  all  lic(  n  iixmI  with  mure  nr  less 
cllicacy.  ( 'hrdiiiic-acid  cautcrizatidii  ha-  its  advocates,  and  al~d  ciiret- 
taii'c. 

Iiiit.  df  all  meihd(1s,  the  Lialvaiii  cautery  needle,  carcfiiUy  in- 
serted directly  into  each  fiiiiLi'oid  dcpo-it,  is  t:cncr,il!v  ackiidwlcdiied 
to  he  more  positive  in  its  results  than  any  of  the  dther  methods  of 
treatment.  This  will  prohahly  necessitate  a  hiri.M'  niimlicr  of 
sittin<2s,  the  use  of  cocaine  or  cucaine  liein<x  in  each  rc(piirod.  Like 
all  other  methods  of  treatment,  the  cure  will  he  tedious:  lint  it  has  the 


oiiu-rii.\i{YN\.     I'liAiu  N<ii:\i,  xmusi^. 


.'«;{ 


m1 
■of 

nf 
<(^ 

lie 


udvaiitajif  (if  jn  rniiiiifiHV  in  results.  A  cure  citii  he  aeeomplished, 
and,  (due  cured,  llie  disi'iise  riirely  returns.  During'  tlie  intervals  hi'- 
tween  operatidiis  the  thrdiit  shmihl  he  treated  liy  aiitise|ttic  sprays, 
twii  or  three  times  !i  day.  Of  all  lliiit  I  have  liird.  nothing;  seems  to 
liave  so  elVective  an  intlueiiee  in  c<uitrollin|,'  the  dc\clupmeiit  of  the 
new  spores  as  a  .solution  of  izal.  This  is  a  enal-produet,  one  of  the  new 
hydrocarhons.  and  said  to  he  much  stronirer  than  earholie  acid  in  its 
^'erm-de-;troyiiii:  iiitluence.  '{"he  preparation  1  have  used  is  a  l<)-per- 
cent.  acjut'ous  soiiilion. 


18 


I 


'M 


('iiAi"n:i{  i-i. 

iivi'Kiri  imi'iiv  nr  iiii;  i.iscr.M.  tonsil. 

Jl  Y^l•;l!■|■|;ll^ll^  of  the  1\  mpliiilic  ti-.-iic.  «ilii;itril  al  the  lia>c  of  ilio 
lon<iii(',  ill  the  i:ln.-Mi-('|Mt:li)il  ic  I'n.-Mi.  i-  iini  ul'  iiilrcijiiciit  oci'iirroiice. 
This   iiiiis.s  111'  iiiiicipiiiiiii-;  lilaiiil.-,   (ailed    tlif   liii'jiial   tnii>il    from   its 


l'"i^'.  ST.      lly|ifi  trii|'liy  ui  Iri't  liiij,'ii:il  tonsil. 
(.Vftcr  l-('iiiin\   jtrDwiic.i 

siiiiihirilv  in  stnictiu'c  to  tlio  liuaial  and  pharyngeal  toii.sils,  is  in 
many  iii.-^tancfs  alniormally  di'vcldiicd.  yivin;;  ri.<i'  to  a  ninrbid  fullness 
and  irriiation,  which  are  hoth  distrossinir  and  .soinowhat  |iainfiil  to  the 


lii: 


it 

t  ■ 


1- ifi'.  x'li.     T?iliitti:il  liyjifi  lrii]iliy  of  liii;,Miul   Inii.sil 
(  .\llt  Imr"-;    .-|icriii;cii.  i 


patient.     The  condition  may  be  ciliicr  unilateral  or  bilateral  (Figs. 
ST  and  STrt)- 

Pathology. — This  mass  of  glands  extends  from  the  cireumvallato 
pa))illae  to  the  epiglottis.    It  is  divided  into  two  halves  by  the  medio- 


()H(t-i'ii  \in  N  N.     in  I'll;  I  i.'nnn    <ir   im;   mmm  w.   iknsii..      •,'>•'» 

gl()ssii-('|ii;:l()ttii.'  li;.Miiiriit.  \\  li.n  m  n  -tnic  <i|  liv|iri  irn|iii_v.  ilio 
^liimls  iiiav  LTiiw  *o  ill)  I'lioniiiiii,  -i/c,  niid  lu'cnmi'  piickod  rlosclv  to- 
^(I'tlH  r  frniM  fide  to  t^idc.  oxer  the  li;i-i'  id  tln'  tniitriic.     'I'licy  iii'i'  Irf- 

»|ll('lltly   .•ircdlllpilllil'd    li_V   the   di'\rlii|illlilll    nf    liW'^c    VcillS,  (■(ilH>ill^   lic- 

tWfiii  till'  l_\  iii|>li(>id  ti>.-ii(' iiiid  llii'  |i;i|iill;i',  t'ni'iiiiii;^'  llii'  liiii;ii,-il  viiiix. 

Sillijcrs  illr  -nliicU  lull  >l|lijr(|  In  (his  dl-Cil-r,  UiiIMill  Mil  II  ii  H  l;l  llv 
(I'i-    N>l. 

'I'lic  iiiiiiii  dill'irtiKc  lictuccii  Ii\  |)crlrn[diy  i>\'  the  lingual   l(in>!l 
iiiiil  of  tliox'  alii'iidy  iiiiini.iii((l  is  ilijii,  while  ilir  hitlor  uri'  lar^'ciy 


{[i!| 


Fi-rs 

luate 
•dio- 


^KrTT\^rM 


l'"iy.  f^''^-      l.iiii;iiiil  \iiri\.      1  Aiilhi.is  "inciiiicii  liy   Wiiiicl 


I.I 


iiu  idriitiil  |o  (■liihlliniiil.  ilic  cnlai^ii'iiiciil  nf  ilic  I'nniuT  I'ai'cly  dr- 
vciops  heJ'oro  niaiurity.  'I'lic  umwih  i>  in  tin'  forin  of  a  Ijroad  layer 
of  cvypts  or  follicles  oviT  the  ha^e  of  tht}  toM,Lnie:  l)t'neath  and  lie- 
tween  \h('<Q  laruo  liliiid  lymphatic  hcdies  are  developed,  iiielo.-ed  in 
lilu'oiis  capsule.*  (Fig.  l^!*).  'I'ho  eomhined  tis.-uis  cidariio  until  the 
sulcus  helwccn  the  tongue  and  the  epiiiloliis  i>.  in  some  instances, 
completely  filled. 

Etiology. -This  hypertrojihic  condition  oecuis  more  rroqucntly 
in  females  than  males:    the  reverse  of  the  historv  of  faiicial  tonsillar 


^  1  , 


m 


rlESf  : 


ysG 


ItlSKASK.s    ol-     IIIK    I'llAltVNX. 


liVjuTtropliv.  rxiswdrth  siijr<rcsls  (Iml  it  ut'ciir.^  iiiiicli  iiioru  fivciiu'iilly 
in  young  cliildrcii  than  i.-  generally  >-ii|)j)().se(1,  not  lioiii,!'-  ri'cogiii/od 
iVdiii  the  fact  n\'  tli('  coiiipaiativc  iiiscnsitivi'iicss  ol  (lie  tlimat  (lur- 
ing early  life.  ('(Uistitiitinnal  (lys<iii,--ia  may  in  iliis,  as  m  dlhor 
]iyiXM'trM])lii(.s,  lijivc  mud,  lo  do  wjtii  its  primary  dcvi'lopnumt.  Not 
jnim[ucntly  it  occurs  as  a  sc(|Ufl  to  diplitlicria.  scarlet  tVvcr.  etc. 
Pooplo  addicted  to  tln'  e\i(»i\c  use  of  spices,  coiidiuieuls.  alcohol, 
etc..  are  also  ])roiie  to  the  disia.-e,  owing  to  tlie  hypcra'mia  produied 
by  their  irritative  action  upon  the  post-lingual  region.  Accordini,Mo 
K'ay.  the  disease  is  of  lii'ijueiit  occurrence  anunig  singer.s. 

Symptomatology. -- Lennox  IWouiie  descrihes  three  forms  of 
chronic  inllammalory  disease  of  tin;  tonsils:  1.  As  .-imple  lym])lioid 
or  catarrhal   inllammat  imi.     '.',    I,acunar  intlammation.     ;!.   j'ari'nchy- 


Vi<r.  Sii.      Mi(i()S(.(i|iii  ul  M'ctinii  of  lulic  nf  liiii,Mud   Imisii. 
I  Aiit  lii;r'^   -!r<'(iinrii.  i 


malou.-  inllaiiimation.  .-oinciinio  ending  in  ahscess,  hut  usually  in 
liypei'lrophy. 

\\'hatever  the  form  may  lie.  the  disease  is  almost  invarialdy 
chronic,  and  of  a  secondary  chaiacter. 

Not  i)ifre(pient]y  clironi<-  hypertrophy  and  lingual  vari.\  are  asso- 
ciated together,  whili'  in  not  a  te\\  \ai'ie(we  veins  will  bo  |iresent, 
without  lymphoid  cidai'gemeut.  'I'he  prominent  >vmptoms  are  ihe 
sensation  of  a  foreign  body  in  the  thi'oat.  nni'elieved  ]\\  swallowing, 
and.  when  the  gi'owth  is  large,  acccnnpanied  hy  a  feeling  of  constric- 
tion (d'  the  lowt'r  pharynx.  'I'heri'  is  (dten  a  rellex  irritahle  cough, 
a  constant  eiuleavoi'  to  clear  the  throat,  laiyngeal  fatigue,  and  also 
occasional  hoarseiuv-s.  in  speakers  and  singers  the  voice  soon  tires 
and  lose-  Volume.     In   many  instances  tlu>  lingual  is  associated   with 


ti 

)ti.« 


l"i\'(liu'iilly 

lllnat  tliii-- 
s  ill  oilier 
nont.  Not 
I'cvi'r,  etc. 
Is,  ak'oliol, 
a  |ir(i(liu'ecl 
(■(■ordiiiii  to 

'  t'onns  of 
V.  lyiiii)lioi(l 
.    I'ari'iiihv- 


\isiially    in 

mvariiilily 

i\  arc  a-so- 
if  |ir('~t'iil. 
lis  arc  lilt' 
;\vallo\vin^', 
if  const ric- 
lili'  couirh, 
'.  and  !il-o 
pnon  tire.'' 
fi;ito«l   with 


(ii((i-rii.\i;  VN  \.      11  vi'i'iM  K'unn    mi     im;   i.im.i  \i,    ru\>ii..      '.'sT 

faiiciai  liyjicrlroiiliy.  W  lirii  varico-r  vi'iii>  an'  |iri'-i'iit  ha'iiinn  l:au;i'  i- 
ofirii  a   |iroiiiiii('iit  syiniuoiii.  (nciirriiii:'  u-iially  in   the  ninrniiii:. 

Diagnosis. —So  many  ihiDai  ilisca-r-  jirnijiu-c  syni|iloins  similar 
to  tlio>f  of  hypertrophy  of  llio  liiijziial  tonsil  that  to  in~iiic  a  corrci-l 
ilia;:iiosis  a  thoroiiLili  throat  cxamiiiiition  ^iioujil  always  he  mailr.  In 
>oiiic  cases  this  can  he  aceompli>heil  hy  the  use  of  the  toiiiiiie-ih'pre-- 
.-•or  wiihniit  further  aiil.  Hut  these  ea.-es  are  ran',  relleeled  liiiiit  iiiiil 
ihinat-iiiirror  Keiiii:'.  in   iiin-^t   iii.-taiiee-;,  rei|nii'i'il. 

.\  mass  of  iiiainmillate<l  tis-iie  will  lie  seen  mi  the  base  of  the 
tongue,  strcleliiiiL;'  from  >i(le  to  -ide  and  divided  in  the  ci'iilro  l)y  a 
loii;:iiiidiiial  depression,  indieaiiiiL;'  the  position  n't  the  Ldosso-c|ii,Ldot- 
tic  li;ianieiil.  SoinetiiiU's  thi'  hypertniphy  nf  ii~-ne  is  so  Lircat  that 
it  (ills  in  the  ulo.-.-o-epiu'lotl  ie  Iioteh  eomplelely.  e\en  nverlappinir  the 
epiLihdiis  ii-elf.  when  ill  the  uprii:lil   pnsitidii  I  P'ius.  s^  and  ST'/). 

Prognosis,- -This  (li-ea>e  in\n|\e~  im  daiiiivr  to  life  and  hut  little 
lo  the  eeiieral  health.  Still,  haviiiL;'  oiiee  di'Vejdped,  there  i-  little 
lil\(dihood  of  aiiHdiiu'ation  of  -yinptom-,  a~  the  growth  i-  >lo\\  ly 
projrressivc,  remaining;'  for  years  withnui  any  leiideiiey  to  shrinka^ic 
or  (diane'c.  In  t!ie  case  id'  varix,  the  e.indjtion  i<  nmre  -erioiis,  as  the 
fre(|uent  liuMiiorrhaiit's  which  are  occasidned  hy  it  are  dehiJiiaiiiiLr  to 
the  cnnstilnlion. 

Treatment.- -  T'lpical  applicaiiiiii.~  n\'  indine.  lilycerii-indide,  soln- 
tioii  (d'  acetic  acid,  chromic  acid.  etc..  have  all  heeii  iimm]  with  more 
nr  less  elVect.  .Still,  ii  mu-1  he  remenihered  that  the  ,::rowili  is  e.--;i  n- 
tially  one  (d'  mature  years,  and  the  nriiine>s  (d'  it.-  texinre  renders  it 
litth^  anieiiah'c   to   mild   method-  df   treatment. 

The  ohject  aiinc(l  at  should  he  reiiinval  nf  the  hyperi  ropliied 
lis-uc,  wheilier  l\inphiiid  nr  \arii-e-e  ur  huth,  'rhi>  can  he  ddiie  in 
\arioii-  wa_\s.  Sdiiie  authorities  ad\i~e  excisicm  h\  ciirvcil  scis.-ors  or 
hi-tnnry.  Others  hy  the  ,L;alvaniicanier\-i''cra-em  ui'  the  cold-wire 
>nare.  The  operation,  howi'Vcr.  which  ha.>  heen  recei\cd  with  the 
,i;'reale  t  fa\or  arid  is  the  iiio-i  l.iruely  practiced,  i-  hy  the  ,i;ahaiii>- 
canteryds7iife  or  elect rocauteryds idle. 

In  any  ca.-e,  (he  pari-  slmidd   he  i  hdrdUiihly  cocainized,  ami   the 

dpcraliot,    sllnldd    he    pcrfolllled    hv   aid    i'|'    I'etlected    liullt.      Tile   ohjec- 

licn  lo  cither  of  the  ciittiii,ir  operations  i-  ihe  pn~>ihility  of  indiiciiitr 
severe  lia'iiiorrhaLi'e  and  the  dilliiiilty  n\'  i-oiitmnini;'  it  in  such  an 
iihscure  .situation.  When  the  ^niui'oii  decide-  to  ii|ierate  hv  either 
histoury  nr  <cis-ors,  it  is  hetter  In  coniim  nee  leinai  ively.  and  not  to 
<'Xpose  too  lari:('  a  -nrl'ace  (d'  raw  ti--ne  at   nue  nperalimi. 


■,]\' 


.*'i. 


~T-i  •iiM-nraMM 


288 


i)isi;.\si:s  VI    riii;   rii  \i;vn\'. 


Olieratioii  li_\  llic  imt  plat  iiiiiiii  ^llal■l'  I  liavt.'  had  im  t'Xpci'ii'nfM^ 
witli,  hilt  would  cxiiccl  the  same  (liHiiiiliy  in  a]i])lyiii,i:'  it  to  Ihe  hroail 
hase  of  iho  ;:ri)\\lh  in  this  as  in  nlhrr  sitiiatinns.  I  liavo  \\<L'i\  tho 
eold-wire  siiarc  on  two  occasions  only,  U>y  removal  of  liyiiertrophied 
lintrnal  tonsil.  In  (hr  (list  llie  opciatioii  and  result  wore  hoth  satis- 
factory. Ill  the  >ccniid.  the  patient  was  a  youiii:  man  ajzed  30.  'riic 
L;rowth  hail  hccn  <lc\clnpin,L:'  fnr  a  ui"id  many  years:  a  fact  thai  I 
did  not  know  iinlil  the  .-nare  was  ti.Liiitly  drawn  arnimd  it.  Then  the 
(•l(i.sest  tractimi  I  could  put  upon  the  wire  faileil  to  sever  the  tonsil. 
Fortunately  for  the  patient  the  part.s  were  well  cocainized.  After 
trying   incllVctnally    for   a   ipiarter  of  an    hour    to    tighten    the    wire 


\i.' 


"\<s.  no.     IIoc's  liiiguiil  tonsillotoinc. 


enough  to  cut  thi'ou,t:h  the  tissue.  T  was  <ihliged  to  sever  it  heucath 
the  .-iiare-rini;-  hy  means  of  ciirxcd  scissor-,  'riii-  is  a  dilliciiltv  in 
ii.-ing  the  cold  >nare  whiidi,  ]ierhaps.  is  not  sulUciently  reali/.ed.  As 
in  the  nose,  so  in  the  throat,  we  sluuild  make  sure  that  we  do  not 
gi'a>p  in  the  giiillot  ine  any  tissue,  liouy  or  li!  irons,  that  tiie  wire  cannot 
readily  sever. 

'{"lie  galvaiioeaulery  operation,  for  both  operator  and  patient.  T 
have  found  in  many  cast's  to  he  the  hest.  'IMie  electrode  should  ho 
eiiiM'd  to  escape  t<uiching  the  body  of  the  tongue,  and.  the  ]iarts 
having  heen  eoeainized.  a  inimher  of  the  larger  nodules  may  be 
touched  freely  at  the  lirst  sitting,  the  patient  grn>ping  his  tongue  and 


I 


mil 


".—i.A.v.sx.     Hv,.,:„T„„n,v  ,„■■  -,.„k  us.,.,  ,„,„,      .,,, 

place     Ihero  .  „o  iuvn-onh.,.     The  snnVnn,  .  n  ^s^    ■       ,     t 
a   U.lo,  a   very    U■^y   iw.iUuvui,   will   .„lli..,.    to   nKror.     ."'"-'""'"'^ 

«!••' "„.„.     1-^KHl  .IHU.M  I.,.  hLuH^u      1^1      '  'r  '  " 

^■n.ten.I.  :uu\  uuUl  ,ui\^,utw  .,ll-.,li„  '  ''^■"'"'^•'-■"ts  n.v 

proe..s  of  heali,,..    /'"  ^^"'   ■'""'""■  ^l"'^'^-'-  -""nn^  nurin^  ,1,. 

Sun,,,  years  a^o  ]{„.,  „[  JJ,„.|...,.,.    ,„,„„,.,,  ^„^  j,,,,,.,,,,,^    ,  ^,,^, 
and  s.iicc  tluMi  various  inodificai  in-       -  '  ■        ■•     -  >'i,_,  .oj. 


I'l-nii.-lif  oiil  l,y  (liir,,,.,.,,!   writor. 


""^  "I  lii:^  nri-inal  .Irsii:,,  have  Wn 


;]! 


i    !- 


(  ! 


i 


r- " 


If 


>   '  1 

,!; 

i  i,  j  ! 

1 

CIIAl'TKU   LII. 


I'.KNKiN    riM(»i;s  III'    IIIK   I'll.\i;\  NX. 


1' ATI  I.I.UMA. 


X  Koi'i,  \>M>  (if  ^cMial  kiiiil.-  ('(■(■ii.-iiiiijilly  iill'cci  tlic  dilTcrt'iil  pm'- 
tidii.s  of  the  |iliiirvii\.  Stiil,  ilicy  arc  all  ciiinparat  i\  cly  rai'c.  I'rol)- 
ahly  ])a))illiiinaia  aic  i^'i  the  iiio.-t  lrc(|iiciil  (Mciirrciicc.  The  usual 
r^ite  is  oil  sdiiic  pail  cT  llu-  ^dl't  palate,  pariiciilarly  tin'  uvula. 
Occjipinnally  tlicy  may  Ik-  fduinl  on  oik.'  of  tlii'  pillar-  nj'  ihc  I'aiicis. 
hut  rarely  mi   the   pharyn.t.M'al   wall.-. 

They  arc  little,  tiriii.  warty  iriowth.-.  SmiU't  imes.  ihnuiili  rarely, 
they  (levclnp  to  the  flianicter  nf  a  ceiitiiiii't  I'c.  ami  pl•e^ellt  a  eaulillower 
or  niaiiimillated  .'-uri'ace.  Tiny  are  wliiti.-h  ami  L;li>tciiiii<:'  in  color, 
and  iiiicror-eopically  c\hiiiit  the  u.-iial  characlcri-ties.  Tli(>y  arc  cnin- 
p(i.-ed  (if  colllicet  i  Vc  tis-lle.  each  [)n|tilla  heiu^f  >upplied  with  its  uWll 
hl(ind-vc>sel  and  coated  o\cr  with  epithelium. 

Xo  special  syiiipt(im<  are  pr<i(|ueed  hy  llieiii.  'I'hev  are  alwa\> 
painless  and  randy  t^ive  any  discoinlort.  When  V(  ry  lai\irc,  particu- 
larly if  attached  to  the  ii\ula.  they  may  prnduee  ci>ul;Ii  and  irritation 
to  some  ,s|ii:lit  extent.  Siill.  ihey  are  rarely  hmkcd  for,  and  almost 
invariahly  are  diseovci'cd  hy  aecideiii. 

Treatment  is  ,-imple.  It  i>  merely  in  ,-ni|i  them  olT  close  to  the 
surface  by  scissors  or  to  seize  them  h;  the  fori'cps  and  cut  them  oir 
at  the  base  by  a  -mall,  shai'p-pninted  liisioury.  When  propicrlv  re- 
moved tbev  evince  no  tendeiicv  to  return. 


i'mitoM  A. 

Fibroma  of  the  pharynx  is  iiiiuli  rarer  than  papilloma.  Occa- 
sionally tins  LM'owtli  may  develop  on  the  soft  palate  or  tonsils.  It 
consists  of  similar  fibrous  tissue  to  libroma  in  other  ]iarts.  and  fol- 
lows a  similar  history  in  development.  The  disease  occurs  most  fre- 
(lut'iitly  in  the  tonsil. 

Fibrous  neoplasms  usually  occ-ur  in  adult  life.  They  ijive  rise  to 
few  symptoms,  the  main  features  being  those  attendinji  obstruction, 
(2  DO) 


ic\l- 
illll 

()>t 

;lu' 
(.ir 
rc- 


It 
Ifol- 

IflV- 

to 

lion. 


OKO-PIIARYNX.      FII5U0MA.  •31)1 

when  tlic  ^i:r()\vth  Inifi  attained  any  largo  sizo.  Not  iiifrc(iufntly  ihe 
disc'ovory  of  the  fibroid  liunor  lias  been  accidental,  the  use  of  the 
throat-mirror,  when  applied  for  some  other  pnrpose,  rendering  its 
presence  apparent.  The  pinkisli-white  color,  ronnded  or  nodulated 
form,  and  rlonse  resisting  consistency  are  prominent  features,  and 
should  render  the  diagnosis  certain.  'J'hey  are  also  less  liable  to  be 
attended  by  ha'morrhage  than  fibromata  of  the  naso-|)liarynx. 

()l)erative  treatment  is  the  only  metiiod  worth  sjieaking  of.  If 
the  growth  is  once  thoroughly  eradicated,  it  is  not  likely  to  return. 
If  it  is  not  removed,  it  will  go  on  growiiig,  displacing  surrounding 
ti.ssues  and  promoting  their  absorption;  and  there  is  possibility  of  its 
ultimately  degenerating  into  malignant  disease. 

Treatment  should  be  by  evulsion.  Sometimes  the  guillotine  may 
be  passed  round  its  base;  and,  as  tibrous  tumors  are  liable  to  be 
jittended  ])y  hirmorrhage,  this  is  an  excellent  jilan  of  removal,  when 
])ossible.  In  others,  the  tumor  may  be  seized  by  tenaculum  or  for- 
ceps, and,  having  been  drawn  out  to  the  tension-])oint,  the  attach- 
ment may  lie  severed  by  scissors  or  bistoury. 

I  liavc  seen  one  case  only.  Tlie  patient  was  a  barrister  48  years 
of  age.  The  growth  was  sessile  and  located  in  the  left  tonsil.  It  was 
whitish  pink  in  color  and  accompanied  ])y  occasional  sliooting  pains 
up  to  the  car  and  down  to  the  larynx.  It  gradually  increased  in 
size  and  commenced  to  interfere  with  speech,  causing  weariness  and 
]tain  after  a  long  address.  In  this  case  I  removed  it  by  repeated 
galvanocauterizations.  The  treatment  was  completed  three  years  ago, 
and  there  has  been  no  return. 

Besides  pure  fibroma,  other  varieties  of  neoplasms  of  a  combined 
character  are  sometimes  found  in  the  pharynx.  Such  as  fibrolipoma. 
a  combination  of  fibrous  and  fatty  tissue;  til)rochondronia,  a  union 
of  fibrous  and  cartilaginous;  tibrolymphadenoma,  containing  the 
fibrous  and  lymitbatic  elements  combined.  lUit  they  are  all  exceed- 
ingly rare,  and  their  history  and  treatment  dilfers  little  from  that  of 
fibroma  in  its  simjde  form. 

]\rention  should  also  bo  made  of  adenoma  of  the  palate,  whiih 
somewhat  resembles  fil)roma  in  history  and  apjiearance,  though  niiicb 
slower  in  development;  and  also  of  angioma,  which  in  rare  instances 
lias  been  known  to  alTect  the  jtalate  as  well  as  the  base  of  the  tongue. 
In  tlie  latter  rem<ival  may  be  by  the  means  already  menfiiuied,  the 
chief  danger  in  operation  being  from  hirmorrhage.  1'his  may  be  con- 
trolled by  galvanocauterizati(m  at  a  dull-red  heat. 


Hi;, 


i:ii 


m 


li    .1! 


ii:    ■ 


I.  1 


I)1m:asks  ()1-  WW.  riiAKVNX. 
l»i;i!Moii)  TrMoiis. 


One  (illiiT  varii'lv  nf  iiiiihus.  tln'  (Icriiio'ul,  is  (Kcasioiiiilly  foiind 
in  till'  |ili:  rvn\.  'I'ln'v  iiic  the  rciiiains  nl'  (Icfcctivf  or  siipcrlhioiis  de- 
vi'ln|)iiiciit  in  iMiiiiniiiiii-  liti'.  Arnold  lias  jiatlicrcd  a  list  (d'  tiiirty- 
ciiflit  dcriiio  il  Illinois  nf  the  raiiccs.  Scvciitct'ii  of  llic^-c  i.ccnrrcd  in 
|picinaturc  -iijl-liorii  infant-,  wliilc  a  lai'yi'  propoi  i  ion  of  llic  rciiiain- 
inii'  "lie-  died  wilinii  a  day  or  two  of  hirlli.  Slid,  a  ihhuIm  r  of  cases 
have  li('<'n  n(ordc(l  in  wincli  children  have  lived  for  a  l(Mi,utli  of  tinic 
with  the  deiMuoid  ii>-nc  still  present,  and  80vt'nil  have  arrived  at  adidt 
a<:e  withnnt    lia\  \\\'j.   it    renioveil. 

The  tnnioi-  i<  formed  of  oidinary  inteiiiinient.  i~  atlaehei]  hy 
])ediele,  and  eoniains  >\\cai  and  sehaeeons  tilands.  a-  well  as  liaii'- 
lollicles.  In  it  there  i-  nothing'  dan.ucroiis  to  life;  and  the  laruc  nmr- 
talitv  ineideid  to  it-  developineid  lias  heen  due  to  vital  insiilliciency 
indepeiideid  of  the  growth.  (Inly  nieehanieal  syni|itoins  are  produced 
by  it.  The  >iirfaee  is  -(dt  and  white.  Sometimes  hail'  is  visible,  and 
the  ap]iearanee  i>  tliat  of  nrdinary  >kin  moistened  by  the  secretions  of 
tlie  throat. 

The  treatment  i-  -iinple  iiinoval  liy  scissors  or  whatever  other 
insti'iimenl  appears  mot  -iiitable  for  the  case.  There  is  no  tendency 
to    reformation   after  cdinplcte  excision. 


ft' 


!.  (. 


ClIArTKi:   UN 


Triu:i!(  ri.(»>is  ok  iiik  i'iiai;^  n\ 


i  I  H 


<)\-  all  forms  of  iniliiny  tiiliciclc.  iliat  nf  the  pliarviix  i>  the  rarol. 
While  (iiic-scvcnlli  of  the  |io|iiilaI  inn  wf  civiliziMl  iniiiit  I'io  die  of  |iul- 
iiioitarv  tiilicrciilosis,  it  is  miiuhly  oliiiialfd  iliat  not  nmri'  than  1 
[)('i-  cent,  of  thc>e  ai'e  ever  alVeetcil  liv  pliai'v  n^eal  I  nherciilar  disease. 
One  nolieealile  feature  ahoiit  it.  however,  is  it-  peeuliai'  \irulenev 
when  developed  ill  the  faiuial  region.  When  in  the  pharviix.  al- 
though usually  considered  an  a.-lheiiie  di-ea-c,  ii  i-,  in  the  inajorily 
of  instaiHi-,  >tlienic.  >evere,  and   rapidly   fatal. 

Pathology. — Wliether  in  tlie  larynx  or  phaiynx,  the  patholoi^ieal 
clinng'c's  very  iiundi  reseinhle  each  other.  .\t  the  eninineiicement  and 
tiirougiioiit  till'  di.-ease  there  i-  a  peculiar  pallor  i.f  tlie  >iii'fai-i'.  The 
lii'st  deposit  of  i^ray  nodnle>  i-  ii.-iially  in  llh'  -oti  palate,  upon  an  a^i- 
noriiially-^ray  niiicosa.  With  this  there  iiia\  he  inlill  I'at  ion  and  ilie 
preseiK-e  of  tuhercle  liac-illi.  I'.y  and  hy  the  nodule-  hirak  down,  and 
shallow.  irre;.;iilar  ulceration-,  witli  ra,::.:ed  ediic-.  take  place,  which 
may  coalesce  and  form  e\leii,-i\c  -iirfaccs  nl  i  iilirniilar  di-ea-e.  Tlic 
tonsils  are  more  rarely  alVectcil.  'I'he  larynx  i-  ii-ually  iii\aded  alniosl 
.syiichronoiisly  with  the  pharynx. 

Etiologj'. — I'harynueal  t  uherciilo-i.-  i>  very  rarely  a  primary  ili.— 
ease.  .\t  all  events,  it  is  i'ecoL;nized.  a>  a  rule,  to  he  a  .-ccoinlary  de- 
\elopnienl.  lollowiiii:-  the  mani  fe-^iatioii  of  t  nlicrciilosi^  in  -onie  other 
orii'iin   (U'   oi'j^aii-       I'ldike   ihe   di-ea-e    in    ihe    lunus.   or   I'xm    in    tlie 

larynx,    it    l-   a--Ulllril    li\     i|>    pre-cHre    to    illduate   llu'   exi.-trllcc   iif   ^-eii- 

eral  lulu  i'culo>i>  in  oilier  origans  nf  the  hodv.  It,-  rapid  clinical  lii>- 
lory  Would  seem  to  liear  oiii  tlii>  view.  .\-  a  rule,  it  i>  a  secondary 
d('\(dopmeiii  to  piilmojiiiry  ili>ea-e.  .Mirrcroinhie  and  (ice  reported 
(■uses  following'  tiihercular  ciiteril-:  ami.  r\r\\  i1iciul:1i  not  primarily 
iccng'ni/.ed  in  othei'  oi',i;ai!>.  it  is  douliifnl  if  ii  i-  mu  pre-ciil.  tlioiiLih  in 
a  latent  form.  Still,  there  appears  to  he  no  rea-on  wliv  a  primarv  dc- 
po.-it  of  tiihercli'  is  not  possihle  ill  ihe  faiiei-.  a<  wtdl  a-  in  any  other 
reunion  (d'  the  Imdy.  and  a  iiumher  of  cax-  ha\e  lieeii  recoi'iied  in 
which  thi-^  seem-  in  have  heeii  the  ca>e.      Li'iiiiox   lii'ow  lie  ha-  reported 

(■.".1:1 1 


\     , 


!  ' 


liJ 


J 


'■vji»»»miiHii 


:.'!tl 


iti^i  \si;s  OF   riiK   riiAiONX. 


.1^ 


III 


h  i 


two  cases  in  wliitli  the  moiilli  and  J'aiico.s  were  all't'ctt'd  willi  luhcrcii- 
losis  between  iwo  and  three  years  bel'ore  there  was  any  nianifestatioii 
in  llie  luii^s. 

Symptomatology.  -A  pa  it  I'rdin  tlio  general  eonstitntidiial  d_v.-- 
crasia,  which  wouhl  indicate  tlie  presence  of  tiiberenhisis,  perhaps  the 
first  directly-pliarynj:eal  symptom  wliich  would  be  noticed  would  be 
pain  in  the  act  of  swallowin,if  or  speaking;-.  This  is  of  a  sharp,  lan- 
cinating character,  and  is  accompani(>d  by  chilliness  and  iiicreaseil 
temperature,  often  rising  to  103°  and  ](tt°.  The  (edematous  condi- 
tion of  the  palate  interferes  seriously  with  deglutition.  Food  will  pass 
up  into  the  nose,  and  secretions  will  accumulate  within  the  ])harynx. 
owing  to  the  stiffness  and  incompetence  of  the  i)alatal  muscles. 
Cough  is  always  feeble  and  accumulations  diflicult  to  void.  The 
voice,  although  mullled.  does  not  lo.«e  its  tone,  unless  the  tongue  is 
atfected:  a  condition  which  frccjuently  takes  place.  DifTicidty  and 
pain  in  deglutition  materially  interfere  with  the  proper  nourislunent 
of  the  body.  Ivxamination  of  the  throat  reveals  the  pallid  condition 
of  the  surfaces,  and  the  presence  of  granulation,  infiltration,  or  ulcer- 
ation variously  combined,  according  to  the  condition  of  the  parts 
atfected. 

Diagnosis.— This  should  not  admit  of  any  great  dilliculty.  There 
are  two  well-recognized  stages  in  the  history  of  faucial  tuberculosis. 
In  the  first  the  mucous  membrane  is  unbroken,  Init  beneath  its  sur- 
face, on  close  inspection,  minute  grayish-white  spots  may  be  observed. 
'J'hey  are  about  the  size  of  mustard-seed,  and  may  be  scattered  pretty 
extensively  over  the  parts  affected.  There  is  also  slight  infiltration 
as  well  as  anaemia  of  the  mucosa.  The  spots  are  greenish  or  muddy 
colored,  (juife  difl'erent  from  the  clear,  white  spots  of  lacunar  tonsil- 
litis. In  the  second  these  nodular  spots  of  tubercular  dei)osit  in  a 
very  few  days  break  down  into  true  ulceration,  of  the  type  ])eciiliarly 
cliaracteristic  of  tuberculosis. 

There  is  probably  only  one  disease  with  which  tuberculosis  of  the 
pharynx  is  likely  to  be  confounded,  and  that  is  the  ulceration  of 
syphilis.  Still,  the  local  conditions  manifested  by  the  two  diseases 
are  strikingly  different.  In  syphilis  the  ulcers  are  clear  cut,  deeply 
excavated,  with  bright-red  irritable  areola,  and  bathed  copiously  in 
yellow  pus.  Tn  tuberculosis  the  ulcers  are  shallow  without  any  well- 
defined  margins,  without  areola,  slowly  progressive,  and  with  limited 
discharge  of  grayish  mucus.  In  syphilitic  ulceration  there  is  no  fever; 
in  tubercidnr  ulceration  fever  is  well  marked.     Tuberculous  "ranula- 


ni{(i-i'ii  \i;vN\.      I  riii'iifii.osis. 


•.'!)."> 


lol"  tho 
Ion  of 
isoasos 
jlt'cply 

^Iv  in 
\vcll- 

imitcd 

If ever; 

nnula- 


tioiis  iire  iiidnlcnt  anil  [lalliil.  \\liile  ;-ypliilitic  jxraiiulatioii-  ai'c  laruiT 
anil   inllainiiialni'v. 

l-npns,  heinjDT  essentially  a  ihronic,  non-felnili'  ili.-caM'.  ciiiijil 
scarcely  be  mistaken  for  tuberculosis.  It  is  also  more  nmlular.  Irss 
painl'iil.  and  <;iven  to  vij;(irous  cicatrization,  to  which  tuberculosis  is 
nnkiiiiu  II. 

Bowlby  relates  a  case  of  (>xtensive  jiluirynLri'al  lubmulosis  in 
which  the  membrane  was  so  e.xtensive  and  thick  and  .ijray  as  in  -ii,::- 
gest  the  possibility  of  diphtheria,  while  Walton  reports  one  in  whiili 
tlie  hard  ])alate  was  perforated  into  the  antrum  of  IIi;.diinore,  render- 
ing a  pnpsil)ility  of  mistaking  it  for  malignant  disease. 

Prognosis. — This  might  be  jironounccd  a  hopeless  disease  werv  it 
not  for  the  fact  that  a  very  few  recoveries  under  favorable  circum- 
stances have  been  reported.  It  is  one  of  the  most  acute  of  all  tid>cr- 
cular  afrcction.«,  usually  ternunating  in  a  fatal  result  in  a  compara- 
tively short  space  of  time.  As  it  rarely  occurs  except  as  secondary 
to  extensive  tubercidar  disease  elsewhere,  it  oidy  adds  fuel  to  the 
existing  fire.  Still,  when  the  nodules  were  limited  to  a  small  area,  or 
a  small  ulceration  existed  without  surrounding  nodular  deposit,  cases 
have  occurred  in  wdiich  prompt  treatment  has  removed  the  local  dis- 
ease and  healing  has  taken  place.  These  patients  might  ultimately 
die  of  tnberenlosis,  but  they  were  cured  of  the  ])liaryngeal  disease. 

Treatment. — On  general  principles,  it  is  better  to  keep  the  part;^ 
free  from  discharges  by  the  use  of  cleansing  sprays.  These  should  be 
of  a  mild  character  to  prevent  irritation:  "JO-iJcr-cent.  solution  of 
peroxide  of  hydrogen  answers  this  |)nr])ose  vi'ry  well.  As  does  also 
a  5-per-cent.  solution  of  resorcin.  Dobell's  solution  answers  a  good 
purpose  likewise,  without  possessing  as  much  antiseptic  power  as 
those  already  named.  After  cleansing,  cocaine  might  be  applied,  and 
the  ulcers  rubbed  with  a  50-per-cent.  solution  of  lactic  acid.  This 
is  after  Krause's  method  of  treatment  of  laryngeal  tuberculosis.  The 
application  may  be  repeated  at  intervals  of  two  or  three  days,  iuid 
may  be  carried  out  in  buccal  as  well  as  pharyngi'al  tidierculosis.  In 
regard  to  the  latter,  I  have  seen  excellent  results  in  a  case  of  extensive 
sublingual  tubercular  ulceration.  This  nccurred  in  a  man,  aged  ;>.">, 
sulTering  from  severe  a[)i(al  disease.  The  treatment  extended  over  six 
months  and  ♦he  idceration  healed,  leaving  the  tongue  somewhat 
limited  in  projectile  movement.  The  pulmonary  tuberculosis  steadily 
advanced,  resulting  fatally  the  following  year. 

Of  newer  remedies,  the  application  of  guaiacf)l  to  the  ulcerations 


fi 


ill 


n :  i|' 


•.".Mi 


IMSI-;  \>i>  or   riii:   ni  \  l,■^  \  \. 


Il'l^  'n'''ll  |ilni||l(Il\|.  ,,r  Mnnd  IVMlll-.  The  -alllr  IllilV  lie  Slid  (if  -lll|il|(i- 
'■ii'illillc  of  lihrlK.I.  |i;ll;lcll|(i|n|i||rni.|.  ;|llil  cll/Vlllnl.  'I'lic  \a\\cV  \~ 
rccniiiliirliilcil   \,y    .Miiiiiiv  ;i-  iiclili-    ill   likr    iiiiiiiii.T   Willi    luetic  iieid. 

A     ."•-    Ill     |ll-|ie|-ee|||.    -|i|;l\     nf    |lie!l|||n|     in    i||i)n|e||e.    t,\-    il    -llniliir 

|'i'''|'iii'iili"ii  ii-eil   li_v  nil  nid-inlialer.  HdiiM  juive  il  ^iiotliiiiL;-  ami  eienii.- 

illi:'    ellVel     ll|i<in    the    ili-ea-eil    li-^iie-. 

Aiiulher  inelliiMl  nf  iivaiiiieiit  III'  pilars  iiireal  I  iilierrii|()>i,-  i>  l.v 
'■iii'''"''iiiciit  anil  laelie-aeid  ireaiiiieiii  enniliined.  a-  advoealcd  iiv 
llrniiii.  If  lli(  [iliysieal  -M-eii-lii  i<\'  llie  palieiit  i-  imt  too  iiiiieli  iiii- 
piiii'cd,  dcsjiiiel  ioii  id  llie  iileeralive  ii-Mie>  liy  i^jilvaiineaiiU'CV  inav. 
ill    -nine    ea.-e-.    elll'ck    llie    [iniiire-.    (if    the    dl-ea>e. 

Aller  eleaiisiiii:-  iir  <i|i(  ral  mn    freijiieiit    diNiiiii;-   li_v   iiid.ifnrin    lia< 

al-n    lii'i'll     fiilllld    of    liellejil. 

Iiitenial  iiiedieaiiiiii  may  al-n  lie  of  lieiietii  \'nv  the  ui'iieral  tiilicr- 
euliiii-  (•(indiiinii.  l-'iir  ilii~  nn  remedy  at  llie  pre-enl  lime  juisses-es 
a  lii.-lier  re|iiila|inii  than  eiva.-iile  and  it-  dei'i\ative.-.  Of  ihe  hil'.er. 
rai'liiiiiale  nf  erea--i)te.  or  ereiisntal.  |iiolialily  lake-  the  liiM  place,  iii- 
•'■-iii'i'li  iis  it  can  he  taken  in  larger  dn-e^  ihaii  anv  id'  the  others 
withiiiit  injiiiy  I,,  the  dii^estive  tract:  do-e-  of  1  or  "J  ^■raimiie>  can 
readily  he  taken  two  or  three  time-  a  day.  eilher  in  codliver-ojl  or  on 
>ii,Liar.  ( dlier  sy-teiiiic  ionic-  and  fernininoii-  niediciiio  mav  al-u  lie 
pn-crihed  in  -iiitahlc  cases,  while  the  dietetic,  hygienic  climatic,  and 
"'li''i'  ciindiiion-  of  the  patient   are  cand'iillv  atleiiilcd   lo. 


(iiAi'i'Ki;  i,i\. 
1,1  ris  ni   Tin:  ni  \in w. 

Li  I'I  >  n|'  I  111-  rcL;iiiii.  ii-  \\v\\  a-  lu|iii-  nf  i  he  skin,  imsc,  nv  hiiN  ii\. 
is  ;i  \cr_v  clii'imii-  ili-c:i-c.  It  i-  ,i  liiri'  ili-ciisc.  sldwlv  pniurrssivc  in 
clijii'iK  tcr,  iiihI  uiiirkiil  liv  iiiHliihir  (lc\  i'lH|iiiirni  iinil  iiilill  liil  inii.  Al- 
tli(in<;li  in  llic  I;ii'^t  lUiiJnriiv  df  in-l;in("-.  Iu|iii~  ;iil;i(k>  the  >kiii  in 
lil'drrcncc  In  ihr  inui'Dn-  nicniliinnc.  lii-i-  iln  miiii',  iHi:i-inniill\ .  in 
wllicll    the   lilltcr    i-    thr    |prinilllV    M'MI    nl'    the   (li-r;l-c. 

Pathology.  Ln|ni-  dillVi-  uiilrlv  Imlli  in  dinic:!!  irL-tmy  uml 
ii|i|iriii'Mncc  I'lnin  Inciil  i  u  I  iiTcn  |u>i> ;  \t\  ilic  prc-fnci-  nf  ilw  I  nl)i'icli' 
liiicilli  in  ciicli  jil'ovcs  llnil  :i  dn-c  ickit  iiin~lii|)  exists  lictwccM  tluMU. 
iiiid   ii   cliisi'   invcstiiiiil  inn    will    rc\ciil    thf    I'iiit   n\'  ;\    tulicrcnlons   cnn- 


, 


I-'i^'.  !M.      I.ii|iii-.     I'alMtiil  ii|i|i(;ir;nicc.      i  After  Lciiimx   lirnvMif.i 


ncctidti  in  llic  niMJnriiy  nf  caM-.     'I'lic  -nit    imlalr  or  niic  nf  lite  raiicial 


iiillafs    IS    iisiia 


llv    the    |iai1    alVi'cttd    lir-i:     at 


III     I'inlil     llii-     it  '*-i,,\\  Iv 


S|if('ai|s    In    the    sni'l    li->ilr.-    n 


r   till'   niiafviiLical    walls   ( \'\ix.   !M  ),      T 


(l('vdn|iin('nl  is  lliat  nf  imdnlai'  t  liickcniiiL;'.  iicc(mii>;mic(|  liy  -Inw 
iiicci'iitinii,  the  pcciiliaf  IValiifc  nf  tlic  iilcci'iilini)  licin:^'  that,  while 
there   i>  (Je-tnidinn   n|'   nininal    ti--ue.   ihei'e   is   little  diiiniii'  of  enlnr 


mil   hut  seaiilv  ijiscliaiuc  nl   pus  ami  ihiiri 


hi  I. 


'he   process  nf   iileer;il  inn    i-   aci-nnipaiiieil    hy   the   eniupensatnrv 


fdi  Miiit  inn  of  cicjit  riciiil  tissue,  whieh.  when  devdnped.  twists  and  inn- 
tnrts  the  pliiirynx  nut  i^{  its  natural  .-liape. 

This  (lisciisc  is  randy  -yinniettieal.  the  lesions  lieinjx  more  cx- 
(onsivc  oil  Olio  side  nf  the  pharynx  than  the  other;  and  the  nodular 
infiltnition   ;ihv;iys    presents   a   ehar;U'leri-tie.    viiseiihir.    kiiol)l)ed,   and 


-«:a 


•-^98 


DISKASES   OF   THE    I-II.\1{VNX. 


irrc<;iiliir  apiiciiniiicc.  'I'li()ii;;li  snmctiincs  nsMitiaird  willi  tiilicriiilar 
(license  in  tlic  other  (ir^iiii-  of  tlic!  Ixxly.  it  most  rriMniciitly  occurs  as 
iiii  iiulcpciKlctit  piitliolofriciil  cnTidilidii  ( l-'i^s.  !••.'  iiiid  !>;}). 

Etiology.-  It  (Mciirs  iiku'c  l'rc(jiiciitly  in  IctMiilfs  tliiin  in  iniilos. 
Wiiy  tliis  is  the  casi;  is  (lilli(  iilt  to  undiTstiind  -tlic  icvcisi'  licin^'  tlic 
case  in  tubcrcnlosis,  its  kindred  diseiise.  'I'lic  period  ot'  life  most 
subject  to  it  is  between  tlie  n<:es  of  ten  and  tliirty  years. 

A  susceptibility  to  tuberculous  invasion  may  possii)ly  be  one 
cau^'c  why  tlic  deposit  of  tlie  liacilhw  tnliereido-i>  witliin  the  pha.'vnx 


y 


Fig.  92.— Lupus  of  lingual  tonsil   ('/.i-incli  oJ)jt'cUve;    Khrlich-Biondi 
stain),     (.\ftcr  Lennox   l!ro\.iu'.) 


may  lead  to  its  proliferation  there  as  lupus,  but  why  it  should  take 
on  that  form  instead  of  that  of  the  more  prevalent  disease,  tuberculo- 
sis, is  the  question. 

What  special  conditions  are  causative  of  its  development  in  any 
given  case  are  still  unknown. 

Symptomatology. — It  is  rare  for  lupus  of  the  ])harynx  to  be  recojT. 
nized  in  the  initiatory  sta<j;e.  as  it  always  develops  slowly  and  almost 
without  symptoms.  Semon  recently  reported  a  case  of  extensive 
lupus  of  the  pharynx  and  larynx  in  which  there  had  never  been  the 
slightest  pain,  although   the  voice  had  been  destroyed   for  months. 


()l!0-ril.\UVN.\.       1,1  ITS. 


yu'.j 


SlitViicfs  (if  ilic  thrniit  iitid  slu^'iiisli  iiidtinii  'if  tlu'  |iiirts  are  aiiioiiL,' 
the  ciirlicst  syiii|iln!iis.  I.iittT  mi  iilcmitinii  develops,  to.^etlier  witli 
iiodiiliir  ('iiliU'^cnuiil  mid  ciciitiiziition.  Dc^lutilioii  ami  plionatinn 
may  Imlh  ]»•  interfered  uitli.  Wln'ii  the  |ial;ite  i-i  seriously  iiivdhed. 
fodd  can  pii-s  into  the  naso-|iliaryiix  and  tlic  nost'  during  the  elVoit 
of  swallow  in  l:.  Still,  with  iiainstakinu;  ell'mt,  suHicierit  food  ean 
always  he  taken  to  sustain  life. 

I'niike  syphilis,  wlu'ii  the  palate  is  aiVecled,  the  hnecal  instead 
of  the  pharyniieid  surface  is  usually  the  seat  of  the  lesion  when  lirsL 
ohserved.     The  a|ipearanee  of  lupus  of  the  uvula  is  also  peculiar.     .\s 


i.i 


.A-' 


lake 
lulo- 

lany 

I'ocr. 

kost 
five 
it  he 
Ihs. 


I'ij.'.  W.i.     I.iii'us  of  liiif.'u;il  tonsil   ('/..■incli  objective;    Ehrlieh-Hiondi 
stain).      (.After   I.eiiiio.'v   I'.rowne.) 

Lennox  llrowne  di'scrihos  it.  the  end  of  tlie  oruan  is  sw(dlen,  with 
solid  infiltration,  and  cluh-shaped  in  ai)pearaii(M>. 

Diagnosis. — One  of  the  notahle  features  of  this  disease  is  its  pro- 
lonijed,  chronic,  non-fohrile  character:  tlic  direct  antithesis  of  it~  fel- 
low,  tuherciilar  jiharyntritis.  The  deposit  is  in  the  form  of  .-mail 
nodules  irrcLiularly  distrihnted.  desfroyinLr  the  smooth  rcjiiilarity  of 
the  niucous  nieinhrane.  AVhen  ulceration  commences,  it  is  always 
limited  and  accompanied  hy  little  dischnrire.  The  surface  of  the 
nodules,  as  well  as  the  ulcerations,  is  of  a  red  color.  As  the  destruc- 
tive process  advances,  cicatricial  hands  form,  which  are  readily  seen 
upon  examination. 

The  pale-pray  color  of  tuherculons  ulceration  should  not  he  con- 

19 


A- 

'Hi 

ii 

Hi 

1-  i 

4.i 

m 

M 

\irr^'-' 


W-':ii 


•Pi 


m 


ll 


;?(M) 


i»isi;.\si;s  oi-    riii;   piiaiivw. 


I'ouiiilcd  will)  lu|iii.-.  'I'lic  ((iliir  iiiid  olijcclivc  form  of  llir  two  diseases 
iii'c  riilircly  dis>iiiiiliii',  while  the  teiiiieious  imico-]uis  of  the  tidiei'eidar 
jiroeess  is  (|iiile  di>tiiicl  fi'oiii  the  s<-iireely-iiuliceal)le  (lisehartic  of 
liip'is.  The  eaehexiii  and  fevef  of  the  one  is  also  in  strikiiit:'  contrast 
fo  the  non-fehi'ih'.  noii-eaehecl  ic  conditioM  of  the  other. 

From  fertiarv  syphilis,  with  its  hroad.  deep  idcei',  shaip  oiitliiu's, 
and  copious  pnrnh'iit  ili-char.uc,  it  should   readily   lie  distinLiuislu'd. 

With  nia'.iLinaiil  disea.-c  likewise  it  has  little  in  coninion.  'I'he 
|iak\  tiioltlcd  sui'face  of  canci  r.  with  its  net-i'osis  of  tissue,  frequent 
liinnoi'rlia<i'es.  oll'ensi\('  disi-liar,i:('s,  etc.,  are  characlei'islic  of  nialiu- 
nanl.  lm(  not  (d'  lupoid.  di.-ca~c. 

Prognosis.-- Serious  and  unfavoralde  as  thi-  disea.-c  always  is.  it 
is  rarely  of  itself  fatal.  It  i~  u>ually.  however,  oidy  a  complication  n[' 
lupus  of  the  head  ov  face,  and  is  siunclimcs  only  a  pi'clude  to  the  more 
x'l'ious  alVection  of  hipu<  (d  the  laryuN.  Still,  in  all  ca,-es  life  may 
he  prolonged  indtdinitely  without  appart-nt  ahl)re\  iati<iii  hy  its 
presence. 

Spontaneiuis  cui'o  rarely,  if  cvci'.  oceui'.  ^'cI  there  are  somc- 
tiiiies.  under  favoralde  cirenm.-laiu-cs.  (pncsceni  pci'iods  in  which  for 
years  little  proi;iess  will  he  made,  and  in  which  ihci'e  may  he  some 
iinprovcment  in  symptom^,  to  lie  lolhiwed  hy  a  I'cturn  of  the  onward 
march   of   the  di.-case. 

Treatment.-  -.\.-  ihci'c  i.-  liltle  >ccrelioii  and  likewi>e  liiile  pidn, 
Jieitlu'r  (dean-iiii;  inu'  anodyne  treatment  i-^  rctpni'cd  in  the  majority 
of  cases.  The  only  treatment  id'  any  use  is  radical,  either  to  remove 
it  altojrethcr  or  at  least  to  check  it.-  progress. 

The  plan  usually  adopted  is  to  scrape  away  as  much  of  the  dis- 
eased tissue  a>  po,~<iliIe  with  a  sharp  spoon  or  curette,  and  then  to 
lirusli  the  lia>ic  >urface  fi'ecly  with  lactic  acid,  the  operation  or  hrush- 
lUil',  or  lioth.  to  he  I'cpcatcd  at  intervals  of  several  days  while  required. 
.\nother  method  of  ti'eatmcnt  which  has  heeii  ri'ccived  witli  a  '^Doi] 
deal  of  favor  is  liy  the  use  of  the  Lzalvanoiaiitcry.  Ivxcision,  too,  is 
luit  without  its  advocates.  l'"i'ec  cocaiiuzat  ion  in  any  case  would  he 
necessary  prior  to  oiieraiion. 

Internal    treatment    hv  arM'tiic.  codlivi'i'-nil,  iron.  etc..  is  als)  a 


iisefid  adiuiiei  to  t 


U'  (iperaln  e  proeeilure 


]|y|)oderniic  injections  of  Koch's  lymph  have  frecpiently  heen 
tried,  ami  the  r(-ult-  I'ceeivt'd  with  more  or  less  enthusiasm,  in  the 
history  of  many  case.-:   ihouuli  whether  permanently  <joo(l  results  have 


heen  accompMshed  in  anv  ol  tiu'i 


n  is  a  mattiM'  of  uraw  dotd)t. 


I  I 


)  a 

ho 
liavo 


svniii.is  OF  riiK  l'lIAl;^■^•\. 

S^  I'll  I  Ms  III'  the  pliiiiviiN  i-  mil  Ky  any  iin'an-  an  iiil'rcijuciit,  evciU, 
and  (icciirs  (hiring:  soiiic  |iiirtinn  nl'  ilic  lii.-imv  of  ihc  majm'ity  of  casis 
(if  >y|iliiliiic  (liM'a.-c.  In  rare  instances  it  is  priinai'y,  in  a  vci'v  lari;r 
iiiiiiihcr  sccdDilary,  and  in  a  rcrtaiii  pi'iipoi'lion  of  ca.-cs  il  dcciii'-  in 
till'  tertiary   I'nrni. 

Pathology.  -  l.e>iiin>,  whether  >ii|iei-ricial  nr  ih'e|i,  are  all  i'\'  an 
inllaininatnry  eharaeter,  and  pafiake  laiLt'ely  nl'  the  nature  nf  ilni.-e 
that  nceiir  (111  the  luneniis  nieinliraiii'  of  the  genital  nruans,  nindilied 
(inly  liy  the  -trneture  and  l'nnrli(in>  nf  the  .-peeial  ti~>iie  n|inn  uhiidi 
they    neelir. 

When  the  primary  di-ea.~e.  m-  hard  cliamre,  a|;iiear>  in  the 
|iha!yii\.  its  usual  site  i.-  in  the  |(in>il,  |pre>i'nlinii'  similar  |iathn|iiL;;(al 
lesions  to  those  nianire-ted  when  il  appears  mi  the  peiii-,  only  thai 
they  ai'e  of  an  aui^'cavated  eharaeter. 

'The  seeondai'y  tnanifestations  id'  >ypliilis  whi(di  appear  in  the 
pharynx  m.iy  he  id'  ilill'creiit  forms:  I.  Mryihenia  or  passive  hyper- 
icmia.  'i'hi-  is  of  venous  ehafaeler.  as  if  the  parts  were  eoiiiic-ted  hy 
(lark,  s!n,L;i:i>h  hlood.  It  does  not  oeeiir  until  two  or  three  months 
after  the  primary  lesion.  ".'.  Miieoiis  patehe».  'riie-e  are  the  ino-t 
fre([iieiit  of  the  sei-onilary  le-mn.-:  and  appeal'  ahoiit  the  ^amc  period 
affcr  the  initial  di-ra-e.  In  the  miieons  pafelie-  Ihei'e  is  dilalalioii 
of  the  hlood-ve>sels  u\er  -  vm  met  iie;i  |  are;i>  npuii  e;ieh  side  (d'  the  -oft 
palate,  with  elViision  of  serum  and  einhryonic  cells.  There  is  inerciM' 
of  cel|-prolil'(M'al  ion,  with  exiidalion  upon  the  -nrface,  tiiviiiLi'  ihe 
peculiar  whitish  appearance  which  is  so  noticealde  a  I'ealnre  of  the 
imicniis  palidi  .">.  'I'lie  siiperlicial  iih-er.  This  i-  another  ,-ccoiidary 
niaiiircslation  nf  the  pre-ciice  of  -yphilis;  Imf,  as  if  is  frei|nenily  the 
result  (d'  iiecro-is  of  miicou.--  patch,  it  i^  not  always  a  distinct  maiii- 
fcsfatioii. 

'I'lie  ferliary  period  (d'  >ypliilis  is  marked  hy  \\\o  development  of 
.iiiimmata,  which  rarely  appear  lad'oic  the  fourth  or  fifth  and  some- 
tinu'is  as  liiic  even  as  the  twentieth  year  of  the  di.-ca-t'.     When  they 

(.".1)1 ) 


m\ 


ii. 


.■:i,: 


i 


A 


•.m 


DISICASKS    (M-    TIIK    J'lIAIiVNX. 


«ii 


o((  ur  ill  till'  jiliiiniix  tlic  dceiicr  tissue's  l)cci)iiic  involved.  'Die  jj^rowtli 
forms  rapiilly,  iiml,  liaviii^-  liniitiMl  vilalily,  liicaks  down  ((iiickly. 
I'atliologically  it  rcsenibk'S  guiiuna  wlierevor  found,  but,  lieiiig  situ- 
ated in  soft  tissues,  necrosis  occurs  earlier  than  when  it  is  situated  on 
cutaneous  surfaces.  Soi'tening  quickly  and  involving  the  di'eper  tis- 
sues, it  forms  the  deep  ulcer  of  tertiary  disease,  the  deptli  of  ulcera- 
tion being  always  limited  by  the  extent  of  the  pre-existing  guniiny 
deposit. 

The  only  other  pathological  conditions  which  need  be  mentioned 
here  are  those  produced  by  cicatrization  of  the  superlicial  and  dt'e|> 
ulcers  of  syphilis.  Jn  tiie  superlicial  the  cicatrici's  are  small,  but 
cliaracli'iistie,  being  stellate  in  outline,  the  fibres  radiating  from  a 
central  mass. 

In  the  deep  the  cicatrices  ])r()duce  extensive  deformity.  Tliey 
are  formed  of  dense,  inelastic  bands  of  tibroiis  connective  tissue. 
These  l)aiids  undergo  continual  contraction,  as  tliougli  Xatiue  were 
trying  to  draw  the  distant  normal  surfaces  together.  .\ot  only  do 
cicatrices  form  across  the  lields  of  iilceratidii,  but  abi'ailcd  surfaces, 
as  between  the  iialale  and  |u)st-]iharynx  or  betwei'ii  the  uvula  and  one 
of  the  faucial  pillais.  will  come  in  contact  and  unite,  resulting  in  per- 
manent destriK'tion  of  mucous  inenibraiie  and  more  or  less  stenosis  of 
the  naso-pharynx. 

Etiology. — Syphilis  of  the  pharynx  may  arise  from  direct  cmi- 
tamination,  or  as  the  residt  of  secondary  or  tei'tiary  disease  in  the 
system.  It  may  occur  as  a  iirimary  lesion  from  direct  contact  of  an 
infect(Ml  siibject  by  kissing  or  Ititing;  from  using  towels,  utensils,  etc., 
infected  by  a  syphilitic  ]iers(in:  or  from  certain  loathsome  practices. 
Max  Thoriier  recently  reported  a  case  of  this  nature,  occiii'ring  in  a 
marrieil  woman,  the  inf"ction  being  direcily  pi'uduced  by  hei'  wretch 
of  a  husband. 

Secondary  syj)hilis  of  the  tlimat  (H-cnr~  in  the  majdi'ily  nf  cases 
i)f  Cdustitntional  -syphilis,  folbiwing  the  general  trend  nf  dcvelnpnient 
of  ..lis  disease  in  the  marginal  mucous  mcinbiaiu's.  oi'  niend)ranes 
near  the  ])hysical  outlets. 

Tertiary  lesions  are  ])roduecd  by  the  constitutional  disease.  Tliey 
are  of  freciuent  occurrence  in  long-standing  cases  and  iray  arise  from 
live  to  twenty  years  after  the  original  primar\  disease.  Secondary  and 
tertiary  lesions  may  also  l)e  liereilitary. 

Symptomatology. — The  symptoms  vary  materially  according  to 
the  ^taure  of  t!ii>  disease  in  which  tliev  are  manifested. 


I  llfV 

from 
and 


()I{(»-I'lIAItVNX.       SVl'llll.IS.  3U3 

In  tlie  priinarv  the  (•]ianci(^  appears  \un>\.  I'rotpu'ntly  ii|ioii  tlio 
t()ii>il.  It  is  usually  uiiilatoral,  l)iit  .-omotinifs  may  occur  on  Ixitii 
>i(lf.-.  J  allien  reports  a  ri'ceiit  lase  in  which  hilalcral  chancres  of  tlif 
tonsil  occurred  in  a  ^rirl  aged  H.  They  were  caused  from  sueking 
the  nipples  of  a  ,-yphilitic  parent,  ret'ently  ilelivercd.  The  s])onjj:y, 
iipeii  condition  of  the  lai'unu'  of  the  tonsils  may  he  the  reason  for  the 
more  ready  deposit  of  the  virus  in  this  region,  hut  other  parts  of  the 
mouth,  the  under  surface  of  the  tongue  and  the  lip,  sometimes  hecome 
tlie  site  of  the  disease. 

The  lirst  symptoms  are  those  of  severe  sovi'  throat,  with  jiaiii  in 
swallow  iiig.  The  tonsil  heeomes  swollen  and  I'ed.  and  a  white  ahrasion 
forms,  with  slightly-elevatiMl  eilges.  Jn  a  I'ew  ihiys  the  gland-  <d'  the 
throat   swell   and   become    painful. 

Seeondarv  lesions,  whether  as  ervthema  or  mucous  naleh,  are 
u.-nally  symmetrical.  Hoth  eruptions  conhne  themselves  to  the  soft 
palate  and  pillar.-,  and  both  show  a  sharp  line  of  demarkatiiui.  Iti 
holh  there  is  slilVness  of  the  throat  and  soreness.  When  the  mucous 
patch  is  |iresent  there  is  acute  sensihility,  particularly  in  swallowing, 
(.nndiments,  acids,  and  hot  ilriid<s  ])rodiice  sharply-distressing  jiain. 

Tertiary  lesion.-.  The  symptoms  attending  the  development  of 
gumma  in  the  ])haryn\  are  lai'gely  mechanical,  owing  to  interfei'ence 
in  deglutition  and  ]ili(ination.  .Mihoiigh  the  pain  may  he  sevi^re.  it  is 
not  sc  lancinating  a>  in  certain  hivms  of  secondary  disease.  It  is  un- 
like the  socomlaiy,  lno,  in  being  unilateral  at  its  coMimencenient. 
usually  attacking  (Uie  tnn-il  with  the  adjacent  ]iiHai's  or  inie  .-ide  id' 
ihi'  post-]iharyngeal  wall.  I»eep  ulceratiDii  ipiickly  follows  the  de- 
■  elopment  of  the  gumma.  It  is  speedy  and  extensive  in  its  desirnctive 
.:clion.  jircsenting  piiimiiKMit  and  ragged  edges  around  the  margin  of 
iic   idcer. 

When  it  remain-  unarrc>ted,  the  destruction  may  be  very  ex- 
tensive, involving  the  intei:riiy  nf  the  ]ialate  and  destroying  ''e 
power  of  normal  deglin  ilion.  fnnd  nnd  drink  iinding  an  entrance  into 
the  n.i.-al  passage-  as  a  consetpuMicc.  1  hemorrhage  (d'  a  seveic  (har- 
acter  rarely  occur-.     Terforatimi  fn^pienlly  takes  i)lace. 

The  symptiini-  ari-ing  fi'nni  cicatricial  deformity  are  almost 
jiUK  ly  (d'  a  mechanical  chaiactcr.  Xa-al  sb'tmsis.  from  (dosnre  of  the 
faucial  isthmu-  nr  adhe>i(in  of  the  palate  to  the  pnst-pharyngeal  wall, 
.- nietinics  occurs.  Cases  arc  on  record  in  which  the  cicatricial  con- 
tractions were  so  severe  that  Hie  naso-pharynx  was  entirely  cut  ofF 
from  the  (tro-pharynx,  and  dlheis  in  whiih  the  jialate  from  side  to 


i-: 


I 


ri 


I*- 
I', . 

I     I 

t 


t1 
:  J 

j 


H; 


;5(i4 


iiisi;.\si;s  ()|-    iiii:  ni.\  uvw. 


1^         5, 


side  l)(Maiiir  a'.liiclifd  t<i  the  |i(i.-t-|iliiii'_vnu('iil  wall.  In  (illicr  instances 
til*'  palate  itsflf  lias  lieeii  Inst,  irivinj;'  the  I'dud  an  e(|nal  (t'lideney  to 
pass  iiUo  the  iias()-j)liannx  as  the  (esophajius.  .Most  of  tliese  del'i)rnii- 
ties  are  irregular  and  of  a  one-sided  eharaeter.  'I'hey  rarely  affect  the 
respiration  when  conlincd  to  the  pharynx;  hut  tre(|uentiy  tiie  voice  is 
clianired   iVoni  the  nnimal. 

Diagnosis. — Chancre  of  the  tiiii>il  prc>cnt.~  the  oi'dinai'y  appcai'- 
aiice  (d'  chanci'e  of  the  pcni>.  with  the  exception  that  il  co\-ers  a  wider 
area.  invoUini:'  the  wliole  of  the  >ni'face  of  the  ton-il.  'I'he  margin 
id'  the  ulcer  i-  indurated  and  the  .-idmiaxillary  and  cervical  ulands 
of  the  all'ccIcMl  >ide  hccoine  enlai':;i'd  and  lender  to  pi'cs-ni'c.  'i'ho 
.-uri'ace  of  the  uh-ci'  is  j;rs"  '•■"  ,  ,i;ray.  and  coated  with  mucus.  Some- 
times, thonuli  rai'cly.  the  .  is  small:  it  may  then  resemlde  more 
fully  an  ordinary  chancre.  .,  dill'cr-  from  i:iininiat(nis  ulceration  in 
not    heiiiL;-  excavated. 

In  syphilitii-  I'rythcma  the  chief  dia,mu)>t  ic  marks  arc  the  .-;harp 
line  of  separation  from  the  healthy  tissue,  and  the  dark.  dilTused  con- 
gestion (d'  the  mucous  nu'inhranc  atVeitcd  hy  the  disease.  'I'he  <oft 
jialate  and  the  faucial  pillais  are  the  part>  ir-ually  inv(dved.  the  po>t- 
l)liarynx  not  hciiiii'  touclici!  hy  the  lcsi(m. 

The  muc(Mis  patch  is  of  a  hlidsh-w  lute  c(dor.  scaltercil  evenly  over 
tile  riu'lif  and  left  sidc>  of  the  jialate  and  faucial  pillar-.  Its  line  of 
doniarkation  is  as  closely  drawn  as  that  of  erythema,  and  is  one  of  th(> 
leading  diagiio-tic  features.  The  thickening  at  lirsi  is  very  slight: 
])iit,  if  the  di.-ea.-e  remains  long  without  contrid.  the  patch  licconu's 
raised  ahove  the  -urface.  the  cidor  more  even  and  opaijue.  ami  the 
margin  develops  a  ring  of  hypciiemia  not  Ixd'ore  noiiccd.  In  soiii(> 
cases  it  hecomcs  li>>ured.  -caly.  and  ha'iiioi  liiagic.  rcsuliiuL^'  in  suimm'- 
(icial  ulceration.  Superlicial  ulcers  are.  as  the  name  implies,  shallow. 
They  are  Usually  ovoiil  in  form,  arc  -harpiv  detincd.  ami  ha\i'  little 
tendency  to  extend. 

(inmmy  tunmrs  are  hard  and  id'tcn  lai'Lic  They  are  paler  than 
the  surrounding  mucosa  and  not  very  painful.  The  diagnosis  is  often 
very  dillicult,  as  they  may  lie  ndslakeii  foi'  llhromatous  or  malignant 
neoplasms.  In  these  i-ases  spccillc  medication  >hould  etl'ectunlly 
estahlisli  the  diagnosis. 

Peep  nleers  of  syphili-  are  much  more  readily  recognized  than 
guniniata.  The  eilgcs  arc  sharply  cut.  the  ulcers  deep  and  depressed, 
sometimes  undercutting  the  snrronnding  mucoiK  memhrane.  The 
marginal   aicohi   is   very  distinct.      I'ns   i-   profusely  discharucd,  aiu] 


11 '  I 


<)1!()-I'I1.\  KYNX.       SYl'lIll.lS. 


305 


|llT 
'H 

hi 
Iv 


necroses  (if  the  iilceiiiti'd  ti^^^u■s  is  a  prdiiiiiieiil  feature.  A>  in  siiper- 
licial  ulcer,  there  is  little  tendency  to  spreading-  lieyoiul  deline(l  limits, 
while  at  the  same  lime,  except  under  specilic  treatment,  i-epair  is 
excecdiniziy  slow. 

'The  cicatricial  tissues  aic  rc<'();:nized  i)y  tlie  -tellate  and  -np.cr- 
tieial  character  of  the  roriner.  and  the  irregular.  e\ten>ive,  and  deoj)- 
scated  pharynii'ciil  defoi'iuities  jiroduced  hy  the  latter. 

Prognosis. — So  far  as  life  i.-  concerned,  it  i-  only  in  the  tertiary 
foitn  that  there  is  any  tendency  toward  a  fatal  issue.  It  is.  however, 
one  id'  the  most  loathsome  diseases  and  also  one  of  the  mo~t  cou- 
taL,^(•ll^^.  :iud.  if  not  I'clieved.  productive  of  almo.-t  life-lom;'  mi-ery  of 
one  foiiii  or  another.  'I"he  liahility  of  tlu'  developnu'iit  of  iiummata 
;ind  deep  idci'rative  pi'ocesses  throULihout  the  dilVerent  li~-ue-  of  the 
iiody  should  lu'ver  lie  lost  siuiit  "f. 

Treatment. — Constiluiioiuil  treatment  is  an  impoitaut  factor  in 
dealiii.i:  with  this  disease.  aii<l  slundd  he  carcdnlly  canied  out  in  deal- 
ing' with  its  various  forms,  particularly  the  two  later  ones. 

In  local  treatment,  whether  primary,  -ecimdary.  or  ti'iiiary. 
tluuoULih  iiiid  systematic  cleansiii^'  is  of  ihi'  ureatot  value.  Thi-  can 
lie  doiU'  hy  alkaline  .frm'frles  oi'  spi'ays.  The  lattei'  when  applied  are 
the  moi'c  etfectual.  When  chancre  n\'  the  tiii'oat  e\i.~t-.  dilVercnt  \]}\i'H 
id'  treatment  are  recommeiii!e(|  hy  dill'ei'cnt  author-.  suh-ei|Ucnt  to  the 
regular  thi'oat-wa.-li.  hut  thcii'  main  ohjects  ai'c  alike.  Solutions  of 
permanjxaiiate  (d'  jioiash.  niti'atc  of  >ilver.  acetate  of  hail,  chhu'ide  (d' 
zini'  may  any  of  them  he  applied  to  the  ulcer  hy  means  of  the  cotton- 
holder:  or  the  vari(Uis  form-  if  ioiliiu'  powd(>rs — such  a-  iodid'orm, 
iodol.  aristol,  etc. — may  he  dusted  on  the  surface. 

'I'he  (piestion  of  reiiunal  n{'  the  chanci'c  hy  cxci-i(Ui.  lU'  of  the 
liypei'trophied  tonsil  up(m  which  it  may  he  located,  i-  lai'cly  scrimisly 
thought  of  miw.  The  virus  is  alieady  in  the  >ystem  when  the  chanci'c 
is  found,  and  the  production  of  a  larijfc  raw  .-ui'faci^  in  the  -yphilitic 
throat  woitld  prodiu'c  -ei'ious  daiiL^cr  of  autoinfectimi. 

M iicdiis  I'lihli. —  In  tins  it  is  hi'.:!dy  impoiiani  to  treat  nio-t 
t!ior(Uii;iily.  the  ohject  hein.i;'  to  desti'uy  the  muciui-  inlill  I'at  ion  as  iMrlv 
as  possihie.  While  the  ]irimary  chancre  is  a  ^eif-limited  disease,  tin' 
mucous  ]ialch.  unless  removed,  will  uo  on  indefinitely  and  may  pro- 
duce chrcunc  throat-lesion.  l"or  this  ther(>  is  no  hetter  remedy  than 
t  he  application  of  niti'ate  (d'  silver  in  strong;"  s(dution.  rejieated  on  alter- 
nate days  its  hmo'  as  the  ilisease  lasts,  cleansinj,'-  sprays  heiiiLi'  used 
during'  the  intervals.    Of  other  reme(lies  that  nnu'ht  he  trieil.  iodoform 


m 


y  1 


1-^ 


;50(i 


lUSKASKS    OF    Tin:    I'llAKVNX. 


I    ■       .  :«.    '; 


i    ! 


m 


iiiu!  j:l_Vf('ri)-taiiiiiii  li;i\f  luith  dniic  irodi!  (Muk.  ;il~n  tiiut.  fcr.  niiir.  in 
;.4yceriii,  1  ])<irl  to  -I.  iiiiiiitt'd  on  the  surl'iicc  time  times  a  day. 

In  the  uh/i'i'utions,  s-upeiliciiil  and  deep,  a.-  well  as  the  gnniniy 
tumor,  Ijcsidcs  tlie  local  clcansiiitf  and  the  aiipliiatinn  of  tlie  iodine* 
compounds,  already  mentionetl,  tlie  main  lliinj,'^  is  to  get  the  system 
under  eonslitutinnal  control  as  ([uickly  as  possililo,  by  the  admiiii  — 
tfaliou  nf  tlie  iodides.  Tliis  treatment  sluiuld  lie  pnrsned  with  zeal. 
in  every  instance  where  a  gnmma  is  discovered,  with  the  object  of  its 
resolntion,  before  ulceration-  with  all  its  destructive  results — cati  taki> 
place. 

The  successful  treatment  o{  deformities  of  the  pharynx  arising 
from  tertiary  syphilis  is  a  very  dillicult  matter.  The  most  CdUimon  de- 
formity is  adhesion,  all  or  in  ]iart,  of  the  soft  ]>alate  to  the  post- 
pharyngeal wall.  -Mthough  tiiese  adhesions  may  lie  severed,  they  are 
followed  by  renewal  of  the  cicatrix,  without  special  means  are  devised 
to  keep  the  parts  open  by  the  use  of  siiitalile  dilators;  and,  as  the 
cases  all  dilTer  from  each  otiu'r,  each  one  must  lie  jiulged  and  treated 
upon  its  own  merits.  A\'hcn  extensive  perforations  of  the  palate  have 
taken  place,  obturators  have  sometimes  been  used  to  prevent  the 
passage  of  food  into  the  nose  or  naso-pharynx. 

.VCI'INOMYCOSIS. 

This  disease,  like  glanders,  is  peculiar  td  the  liiglier  animals;  but, 
instead  of  selecting  the  horse  as  itt;  haliitat,  it  has  chosen  the  bovine 
race.  Like  glanders,  too,  it  is  communicable  to  man.  In  cattle  the  dis- 
ea.'se  is  known  as  '*lumpy-jaw."  and  owes  its  origin  to  the  ''ray-fungus." 
it  may  be  transmitted  to  man  liy  enntagion  through  an  abradecl  sur- 
face, and  from  then*  tarrieil  by  the  lymph-vessels  to  the  pharynx  and 
tonsils. 

The  implantation  of  the  ray-fungus  leads  to  dcvehipnient  of 
granulation-tunuirs,  which  result  in  inflammation,  chronic  suppura- 
tion, and  fornuition  of  ill-conditioned  sinuses.  The  symptoms  are  thos(* 
of  local  tumefaction  and  persistent  purulent  discharge.  Tain  is  vari- 
able and  is  of  a  heavy,  aching  character.  Sometimes  th(>  disease  might 
be  mistaken  for  sarcoma.  'J'he  jirognosis  is  bad,  althotigh  early  treat- 
ment might  be  of  some  avail.  Large  doses  of  iodide  of  potassium  are 
said  to  have  cured  some  cases.  Nitrate  of  silver  given  internally  has 
also  been  attended  with  good  results.  In  suitable  cases  extirpation 
of  diseased  tissue  should  be  ac(-omplished.     (Kyle.) 


\ 


!■  I 


CJIAPTKli  LVI. 


SARCOMA  f)F  THE  FAUCES. 


i.'    I 
'  ■  ■  .  '  ; 

1  .  ' : 


)Ut, 

iiio 
-iir- 

Ulll 

of 
ii'ii- 

ari- 
-liit 
^at- 
arr 
Tias 
lion 


This  is  a  (.onipaiatively  rare  disease.  It  occurs  more  freiiuenlly 
in  the  tuiLsil  than  in  the  soft  palate  or  [lost-pliaryngeal  wall,  riilly  ono- 
liali'  ol'  tlie  cases  I'epurted  liaviiii:  oceiiired  in  tin;  tonsillar  region. 

Pathology. — Sareouia  dillVrs  little  in  physical  characteristics 
wherever  found.  ]t  has  a  greater  tendency  to  localize  itself  than  car- 
cinoma, and  when  it  develo{)s  in  the  tonsil  it  grows  more  rapidly  than 
in  the  ]ialate  or  ])Ost-pharynx.  When  located  in  the  ]nilato  it  extends 
somewhat  slowly  and,  as  a  rule,  in  a  liaekward  direction.  In  the 
tonsil  the  spongy  nature  of  the  lymjiliatic  tissues  favors  more  rapid 
growth.  Infiltration  becomes  extensive  and  the  disease  jn'ogresses 
toward  the  oro-jjharynx  and  into  the  deejier  tissues  of  the  neck.  Be- 
sides the  greater  rapidity  of  its  development,  in  one  other  feature 
does  sarcoma  of  the  tonsil  dilfer  from  sarconui  commencing  in  the 
faucial  regions,  iind  that  is  in  it.-  ("iideiicy  to  exti-nd  through  the  neck 
to  the  outside.  There  is  no  iixel  rule  of  development,  however, 
wherever  the  disease  may  he  located.  Chiari  points  out  that  frequently 
large  tumors  are  formed  in  tlie  pharynx,  mouth,  aiul  upper  jaw,  and 
the  malignant  growth  may  even  extend  to  the  larynx,  orbit,  and 
cranial  cavity,  accompanied  by  deep  and  wide-spread  ulceration. 

Several  varieties  of  this  growth  occur  in  the  pharynx  and  soft 
palate,  though  ])erha]is  the  most  fre([uent  art;  what  are  called  the 
round-  and  s])iiulle-  celled  sarcomas.  ('a<es  of  myxosarcoma,  adeno- 
sarcoma,  lymphosarcoma,  fibrosarconui,  and  giant-ccllcd  saicoma  are 
also  reported. 

It  is  the  small,  round-celled  sarcoma  which  occurs  most  fre- 
(picntly  in  the  tonsil.  The  cells  are  similar  to  those  of  the  lym])hatic 
glands,  but  their  nuclei,  while  round,  are  larger.  The  spindle-celled 
sarcomas  occur  very  rarely  in  tlie  tonsil,  and  the  large,  round-celled 
rarely,  if  ever. 

Etiology. — There  is  no  definite  cause  known,  up  to  the  ]irescn(, 
for  the  development  of  this  disease,  no  nu'thod  of  ascertaining  before- 
hand wliy  it  should  arise  in  one  person  and  not  in  another,  no  means 


W 


i'i!. 


30.S 


DISKASKS    (tl-    Tin:    IMIAItYNX. 


Hi 


ul'  aiiiilvxint;  ilii'  s|i('ciiil  cniidit ions  fs.-cntial  to  its  ronnalinii,  ami 
pniiilicsviiiu'  (Iclinitcly  \\\v  (•(uiiinj:  rcsiill;.  Certain  [prciniscs.  arc.  how- 
over,  known.  l'"or  instance,  it  occurs  much  more  t're(|ueiitly  in  men 
than  wimirn.  I'nlike  careinoma  it  I'reiiuently  alVects  ehildliooil.  while 
it  is  known  to  occur  durinir  all  the  a.ues  of  mainri'd  life.  If  there  is 
any  preference  in  this  matter,  sarcoma  of  the  tonsil  e\hil)its  a  iirt'atcr 
Iciidciicy  to  dc\clo|i  dnriiiu'  ihc  i  .\ii  cMi'emes:    childhood  and  oh!  a^i'. 

Symptomatology. The  dcvel()|iment   of  sarcouia   varies   ^rrcatly 

aceordiiiir  to  the  situation  and  viruleiux^  of  the  disoase.  in  the  jialalc 
it  may  come  on  insidiously,  and  give  little  indication  id'  its  presence, 
until  de<,dutiti(ui  and  phonation  is  interfered  with.  There  may  he 
little  cachexia  and  no  Ldaiidular  enlargement;  hut,  when  the  growth 
is  attached  hy  ])edicle,  the  mechanical  presence  of  the  dep(>nd(Mit  lioily 
may  give  rise  to  laryngeal  symptoms. 

In  the  tonsil  the  symptoms  may  eomc  on  more  rapi<lly  and  1)(> 
earlier  felt.  .\t  lirst  it  might  he  taken  for  (piinsy,  hut  the  latter  is 
moi'e  rapid  and  accompanied  hy  fehrilc  action.  As  ulceration  de- 
velops, luvmorrhage  not  infrequently  occurs,  accompanied  hy  olfensive 
discharges  of  pus  and  dfhris.  Jn  tonsillar  sarconui  the  deep  extension 
nuiy  pass  quickly  through  to  the  outer  wall  of  the  neck,  whei'e  it  ho.- 
comes  hard  and  nodular.  Swelling  of  the  neighhoring  glands  occurs, 
and  the  cachexia  of  malignant  disease  is  more  readily  noticeahle. 

Sarcoma  of  the  pharyngeal  walls,  like  sarcoma  of  th(>  palate, 
seems  to  have  less  malignancy  in  detail  than  that  of  the  tonsils, 
'{'here  may  be  less  jiain,  less  haunorrliage,  and  slower  develo|)nuMit. 
The  glands  are  less  involved  and  the  cachexia  less  marked.  Still,  the 
geiuTal  symptoms  are  present  in  ail.  and  each  case,  no  matter  ■nlien- 
situateil,  is  IkudhI  hy  no  fast  rules  of  clinical  history. 

Diagnosis. — The  (hief  diseases  from  which  sare(una  of  the  fauces 
has  to  he  distinguished  are  adenoma,  fihronia,  and  carcinoma.  In  the. 
palate  sarcoma  has  a  light-reddish  c(dor  and  is  rounded  or  no.lnlated 
in  form.  Jn  the  tonsil  it  may  he  o\'  a  darker  red.  while  in  the  pharvnx 
it  may  he  of  a  still  m(U'(>  purplish  hue  and  mottled  in  ontline.  l-'rom 
carcinonui  it  is  distinguished  hy  the  harder,  almost-cartilaginous  oul- 
Hnes.  as  well  as  lighter  color,  of  the  more  malignant  disease.  The 
latter  also  spreads  with  greater  facility,  and  is  accom]ianied  hy  more 
extensive  glandular  enlargenuuit.  Sarcoma  extends  backward  and 
outward  in  its  growth,  while  carcinoma  usually  has  a  forward  develop- 
ment. 

Fibronui  of  the  pharynx  is  a  very  rare  disease,  slower  in  develop- 


I.  I 


(>U()-1'1IAI!YN.\.       SAlii  DM  A. 


;50i) 


,ilc. 

Iriils. 
Mlt. 
the 

KTr 

IICOS 

iiteil 

VlIX 

rmn 

(Htl- 

hr 

Kirc 

laiul 

|l()p- 

lop- 


iniMit,   :iii(l    uiiaiicnilnl    li_v    Lilaiidular    -yiiipatli} .      AiK'nmiia,    tuo,    is 
-IdWiT  in   Ini'iiialioii  ami  Ic.-s  likrly  to  iilcciati'. 

'j'lii'  |ins.-il)ilit_v  (i|  mirtakiiii:-  at  lirst  ~i,L;lil  .-arcoiiia  nf  tho  ti>ii>il 
I'or  (juiiisy  has  alriatlv  \>vvn  ii'lVrrod  Id,  but  tho  lad  that  tho  latter  is 
an  aciito  iiilhiniinatdrv  discasi'.  with  tho  attoiulinii'  sviiiiitunis  so  i-asv 
to  I'ccou'iiizo,  shouM  at  once  I't'Miove  all  doubt. 

The  liacitliis  ol'  >aii-niiia  ha-  so  far  imt  been  di.-cdVcrcd ;  but  in 
laih  case,  if  ]K).-sibh\  a  ini(!'(iM(i|iical  rxauiinat  inn  df  n  minutt'  si'dimi 
nf  tlic  ueoplasin  should  be  made,  to  dcuhuistiati'  the  prcsciue  of  liu' 
crlN  indicative  of  the  disease. 

Prognosis. — Allhouiih  a  very  iirave  di.-easc.  it  apjtears  to  bf  much 
111  '  auK'iiabU'  t(i  ii'cal  incnt.  whm  .-ituatcd  in  the  ]ialate  or  nharvnx 
than  when  located  in  the  tonsil.  In  any  ■situation  there  is  no  tendency 
to  sjioiitaneous  cure,  but  in  tiic  two  I'oiincr  siicccsslnl  removal  has 
been  accomplished  more  tfeiiui'Utly  ihan  in  the  latter,  with  a  certain 
arnonnl  of  immunity  from  future  return.  In  the  pharyn.v  the  lirowlh 
is  often  pedunculated  and  lemovalde.  in  ihe  tonsil  the  allachnient 
is  broad  and  ileep,  owiiii:  to  the  niixeil  character  of  the  tissue  in- 
volved. The  lym]»haties  cd'  the  ton>il  li,i\e  also  intimate  connection 
with  tin  underlying  lymphatics  of  the  neck;  this  may  possi!)ly  ac- 
count ior  the  ,i:reater  inaliiiiiaiiey  \\hen  situateil  in  this  reL:i("in. 

in  the  palate  enucleation  fi.ini  the  >iirroundinu-  tis.-ues  has  in  a 
numbei-  of  in>taiu-es  been  attended  with  the  best  residts.  The  dura- 
tion of  the  disease  may  be  bi-iwcen  ,-i\  months  and  two  or  three  years. 

Treatment. — This  uiay  be  divided  into  palliative  and  operative. 
Of  the  former,  cleansin.i:'  washc-  of  an  unirritatinL;  and  a>cp;ie  char- 
actc'r  may  be  reipiir(>d  to  kei'p  the  part-  free  fiom  nuiideiit  >eci'etions. 
This  wiiii  .-npportin,^'  nu'asures  is  all  that  can  lie  done.  (>f  internal 
ronu'dies,  he  adnnni^tration  of  arsenic  seem-  to  be  hehl  in  the  higliesi 
favor. 

Of  operative  treatment,  there  is  110  livid  inh'  for  the  liiiidanco  of 
the  sui\i:('oii.  except  the  uecessity  for  the  removal  nf  the  I'litirc  m-o- 
plasm  when  at  all  possible,  if  the  iirowth  i.-  pedunculated,  ablation 
by  the  snare  is  the  best  method  at  our  command.  This  may  be  either 
by  the  cold  wire  or  the  iralvanocautery-ecraseui'.  and  particularly  ap- 
plicable when  the  disease  occupies  the  ijluirynm-al  wall.  A\'hen  ses,-ile 
lU"  nucleated,  excision  may  be  necessary.  It  is  always  better  to  operate 
directly  through  the  moi  Mi  when  jmssible.  At  otlu'r  times,  when  the 
external  wall  is  afl'eeted.  the  tonsil  being  deeply  involvt'd,  lati'ral 
])haryngotomy  may  require  to  b(>  resortecl  to.     'i'he  main  thing  in  all 


It' 


iil 


! 


\k 


'<    . 


^;!ii 


;n(i 


1»I>>EASKS    or    Till-;    |-]I.\UVN.\. 


cjiiit'S  is  til  niiikt;  the  dia^irno^ii  jiositivo  a-;  early  n^  pos.^ililo;  and  then, 
if  there  is  any  i)robability  of  a  good  result,  to  njitrate  as  ilionniifhly 
ns  possible  and  without  delay.  As  to  the  inetliod  required,  or  tln' 
instruments  to  be  used,  each  I'ase  must  bo  carefully  considered  iiiion 
its  own  merits.  'I'lie  operator  should  be  guided  l»y  the  liest  jud:,Miu'nt, 
either  siii,t:ly  or  in  eonsultalion,  always  remembfrim:  the  ii(i.-.-il)ilily  of 
severe  hivmorrhagc,  which  operations   in   this   locality   are   liable   to 


pro 


ducc 


Lkckoit.akia  r.\i. a n. 


Ibis  IS  a  conditidii  which  sonictim(>s,  ihuiiLrli  rarely,  aliects  the 
anterior  border  (d'  the  S(d't  palate.  Althouah  not  i  arc  inomato\is,  it  is 
said  to  bear  an  intimate  relation  to  cancerous  ilisease;  and.  if  not  re- 
nuncd,  des(|iiamation  -nay  sot  in,  with  the  linal  result  id'  the  dev<'lo])- 
mi']it  of  nialii;'nancy.  .\s  its  name  implies,  it  is  distiniruisbed  by  the 
development  of  little,  white  plmjiirs.  v:v\'/]u;j  from  one  or  two  milli- 
metres to  a  eeiitimetii'  ill  iliaiueter.  diH^  ;o  tally  dcLreneratioii  of  the 
siii'facc-epitlieliiim. 

'i'l'eatiiieiu  >hoiild  !:■■  local  a|)plica{i<)ns  rf  nitrate  of  silver,  ehromie 
acid,  or  electrociiutery.  to,<rether  with  the  us  ■  (d'  mild  antiseptic  sprays. 
Systemic  tre-tment  should  be  of  a  supportiiii:  character. 


..jl, 

1 

ClIArTKi;    I.\  II. 


(  AlK  INO.MA  ol'  'IIIK   KAICKS. 


ial! 


Silt  MoiiiJ.r,  M.\rKi:N/i  i;  (Iciliuil  eiiri'iiioiua  iti  tliis  rogidii  as 
"priiTiarv  iiiali_i:na!it  disease  of  the  jjharvnx,  generally  oaiisin^  death 
by  stai'vation.  Imt  sdiiirtiiues  iiv  lia'iiKU'rhaire"'  (I'ijr.  !*l).  At  the 
present  time,  while  this  dctinilitm  iniLihl  he  ruLsidcri'd  lari^ely  enr- 
vcet,  a  good  deal  of  wi'i^ht  wmiM  he  jilaced  upon  the  inlltu-iiee  r)l'  the 
toxin?,  evolved  from  cnnemms  growth,  in  hastening  the  fatal  resnlt. 


■^^-v... 


Fip.  04-  Miilifiiiant  I'liitliclionia,  cxtfinliiii:   frdin  liytit   tcii-il   to  Imsc 
of  tonfTUO.     (Aftfr  LriuidX   Urowiici 


Pathology. — 'i'he  ]>re\;iiling  i\|ie  of  canecr  nf  the  fauces,  whether 
in  the  tonsils,  soft  ]ialate.  or  jiharyngeal  walls,  is  epithelioma.  When 
located  in  the  soft  palate,  the  history  of  the  eases  reported  seems  to 
indicate  a  temleney  not  to  spread  very  widely  heyond  the  muscles  of 
that  organ.  Whatever  extension  does  occur  is  usually  toward  the 
pillars  and  tongue,  rather  than  the  pharyngeal  tissues  as  in  sarcoma. 
Tt  has  been  noticed,  in  refei'ince  to  this  disease,  that  when  it  com- 
mences in  muscular  structure-;  it  apjiears  to  avoid  lymphatic  tissues 

('"11) 


I 


m 

iiil 


M 


in. 


..I".'  DISKASKS    OK    TllK    l'll\l!\N\. 

Ill  il>  I'Mciii-ioii,  whcrciis  when  il  lia.-  its  oriiriii  in  lviii|ilialiL'  hndics, 
as  ill  Ihc  iipii^il,  It  ,>|iit'a(ls  iti(lisi'rimii)ati'ly  to  llu;  surroiuuliiig  tis-siios, 
III!  iiiatlcr  wliat  their  ,-1  iiicliirf  may  lii'. 

()|iiiiiniis  arc  (li\iilc(l  as  to  llic  i(iiii|iarativo  frcciiicncy  of  sarcmiia 
ainl  carcinoiiia  of  tlic  fauces,  reiliaps  the  wciLrht  of  opiiiioii  is  willi 
(he  latlt'f.  There  is  this  diU'eieiKc,  howcNci',  that,  while  .-arcoiiia  of 
the  throat  occur-  frc(|ueiitl_v  duriii;;'  caiiv  life,  careiiioina  )trevail> 
ihiriiij;  the  iiiiihlh'  and  hiler  periods,  huriii,^'  iiialiire  year.-  the  lyni- 
phatii'  structures  of  tlie  tliroat  undeiLiit  shriukajjfe  and  diuiinishi'd 
aetivitv,  wliile   the   eiiithelial    and    eMnnrriive-ti«-n('   elenieiils    retain 


lij,'.   fK").     .^liatilicd   ('iiitlieliiJiiia   di'  inn-iU    i     _  iiK  li   ul)JL'c'ti\e) . 
(AfttT   I.cmiiix   llrDwiie.) 


1     '1 


their  aptitude  for  inereased  dovelo|)iiieiit.  If  from  any  cause  this  epi- 
thelial proliferation  heconies  siiinulatcd  to  an  ahiioimal  deijree,  avc 
have  a  condition  favoi'ahle  to  the  formation  of  cancerous  tissue,  which, 
forming  first  superlicially,  ])enclrates  deeper,  displacing  and  invading 
minnal  tissue  as  the  ci)itlielial  deposit  increases. 

Ill  all  parts  of  the  fauces  the  development  of  cancer  f(dlo\\s  the 
ordinai'y  couive:  rapid  formation  of  the  tumor,  followed  by  peripheral 
•ulceration  and  hannorrhagic  discharges.  When  located  in  the  lower 
jiharynx,  the  tendency  of  the  disease  is  to  spread  downward,  involving 
the  (esophagus  and  larynx:  when  in  the  tonsil,  outward  ami  forward 
as  well  as  toward  the  pillars:    whili'.  as  said  Ixd'ore,  its  fust  develop- 


(•|;n-ni  \K^  V  \.      (  AIMINOMA. 


;!i;; 


llicnt  iilnnii;,'  the  iiiiimI(>  oI'  llic  Mill    |iii!iilt'  is  fullnw't d   liy  a  li'iiilfiicy 
to  yclf-liTiiitiition. 

ilistnldiiiciilly  {'pitliclin'iia  (if  llic  jdii-ils  n|i|i(ar<  in  twn  forms: 
1.  'I'liat  of  >li'alili('il  ('|iitli(liiiiiia  willi  liniliriatcd  proocsscs  (l'"i,i:.  !•")). 
''.  Tliat  (if  (•(■ll-iicst  (l('Vi'l(i|iiii(nt  aldii.i:  the  Iraik  (if  (lie  lym|i!i-V('Ssols 

Etiology. — The  avcraLic  aire  nf  pci'-mi-  alllictcd  \iitli  carciiKUiia 
(if  the  )iliannx  is  sdiiicwliat  almvc  llfty  yi'ai->.  'This  in  males  ami 
fcniiiU's  is  about  alike;  luit  hdc  curidiis  fact  is  iKiticoaUle  rolativc  to 
the  cases  so  far  rcrorded,  and  thai  is:  while  twiee  as  many  males 
have  cancer  of  the  palate  and   |(in.»ils  as   females,  the  reverse  holds 


Fip.  O'la.     I'^iiitluiidina   slidwiiif;  (('ll-ncsts    ('/Vini'h   (ibjectivc) . 
(After  I.ciiiKix   l?ni\vii('.) 


M 


f  ii 


01)1- 

\ve 

ueli, 

liny 

the 

leral 

|)\ver 

i-in<r 

lard 

lop- 


<;ood  in  reference  tn  cancer  of  the  lower  pharynx.— nidre  than  two- 
thirds  of  the  cases  repdrted  have  dccuri'ed  in  wcinen. 

Of  the  various  rcirions  of  the  throat,  it  neciiis  most  fre(piently  in 
the  tonsils,  the  lar;:-esl  nundier  oceurrin;:  hetween  tln^  a,ircs  of  forty  and 
fifty  years. 

'  Ueredifary  tcjidency  has  somethinii  In  do  with  it>  developnumt. 
Init  how  much,  it  is  dillicult  to  -.ly.  Ivxposnre  to  vicissitudes  of  out- 
door life  is  also  said  to  he  a  cause,  as  also  the  c.xccs.sive  use  of  alcohol 
and  tobacco. 

Symptomatology. — When  confined  to  the  palate,  and  also  when  it 
has  its  origin  in  the  jduirynjieal  wall,  the  early  symptoms  are  chiefly 


;,     .1 

I 


III 


I         i 


311 


DISKASKS    ()|-     IllK    I'llAltVNX. 


tlioso  ol'  ii  iiiccliaiiiciil  rliaracli  r.  TIiltc;  may  \)v  ililliciilty  uf  .swallow- 
in;:  and  al.-()  inullled  voice;  hut  ihcro  is  no  level',  no  liyi)erseerolion 
of  mucus,  and  but  little  pain.  On  tlie  other  liand,  when  t'<e  toiLsil.s 
arc  the  seat  of  the  disea>e,  .-iiarj)  and  lancinalin,ij;  pains  aie  among 
tlic  earliest  .«}'niptoin.<.  'J'hese  are  felt  ehielly  in  deL^lutitioh,  and  as 
the  disea.-e  advances  iiicieasi'  in  severity,  'i'hey  I'adiate  in  dilVereiit 
directions  from  tlie  part  airecled,  hut  chietly  toward  the  ear.  As  the 
tumor  develop.-  eithei-  in  ihe  pahite  or  tlie  pharynx,  the  paiii.s  also 
become  more  severe,  ihoiiuh  they  are  jimhably  never  so  e-\erueiating 
a.s  ill  tonsillar  carcinoma.  I  h-eialion  is  usually  a  comparativ^dy 
early  symplom,  and  in  the  tniisils  as  well  as  the  ])liaryn\  is  mure 
likely  to  he  foUowi'd  l»y  iKenmri'liage  than  in  the  jialalal  disease. 

Increased  ilow  of  saliva  is  also  an  early  sym|iioni,  the  salivary 
glands  being  stimulated  to  hyperseci'etion;  iiein-e  di'uling  is  often 
present. 

'J'lic  cei\ica]  glands  hecnine  enlarged,  pai'licularly  in  tonsillar  or 
pharyngeal  disease,  and  the  early  development  of  cancerous  cachexia 
is  of  frequent  iiccui'i-cnrc, 

A\'hen  the  tlisease  is  situated  in  the  lower  pharynx,  its  extension 
lo  the  (esophagus  and  larynx  interfere  decidedly  with  b.ilh  deglutition 
and  ])lionation,  and  alsn,  as  the  disease  beconies  more  severe,  with 
normal    breathing. 

Diagnosis. — The  disea'^es  of  ;lie  I'ances  from  which  carcinoma 
]•  st  be  distinguished  are  ehielly  those  of  saii-oma  and  fibi'uma.  The 
lailer  is  more  rare  in  this  r^'ginii  than  carcinoma.  1'  is  slower  in 
growtli,  is  nnattciiiliMJ  by  coi-slitui  innaj  cachexia,  is  pi'ddndivc  of  less 
]iain,  and  is  usually  peilnncuhueil  and  t'linseipieiitly  mnvabli'.  On 
the  tirst  ajipearaiice  of  the  neoplasm,  liowever,  before  serimis  symp- 
toms have  had  time  lo  (leveb']i.  there  may  in  some  eases  be  room  for 
doubt;  but  these  will  soon  vanish  by  a  careful  obser\ance  of  the 
])rogress  of  the  disease. 

l'"roin  sarcoma  the  distingni.-hing  lines  ai'c  less  clearly  drawn,  ex- 
cept in  typical  cases;  and  it  shonbl  be  n'lnembcred  that  in  many 
cases  the  imlications  (»f  the  two  diseases  so  overlap  each  (4her  tiiat 
withont  microscoiiical  examination  it  is  almost  iuipossible  to  arrive 
at  a  positive  conclusion. 

The  typical  sarcoma  is  a  soft,  red,  tleshy  tumor,  not  -nueh  given 
to  ulceration  and  slow  in  f(vming,  while  typical  carcinoiua  is  harder 
even  than  fibroma,  cartilaginous  to  the  touch,  and  of  a  Mhiti.sh-red 
color  and  riodnlated.     'i'he  cervical  glands  become  involved  early  in 


Il'l." 


ci;i 


ith 

ih;i 
\w 
in 

On 

iip- 
for 


'X- 


liiy 
liat 


YO 


|(MI 


lin 


\ 


t)H()-l'll.\i:  V.W.       (  Al;i  INd.MA. 


ciirciiKimii.  while  in  sarcniiia  they  are  laic  in  hcciuninii  .:•■'•  ,c(l.  In 
the  saiiic  way  the  inalijiiiaiil  cachi'xia  is  imich  more  early  in  il.s  maiii- 
I'estations  in  the  Inrnier  ihaii  the  latter. 

( 'areini'iiia    nt    Ihe    Intisil.    uhiih    i-    ii-ii:ill\'   scii'i'hn-.    i~    haiihr. 


w  liiler,  ami  di 


n-er  Ihan   -^aiciima,  much    mmc  jiai 


nl  III.  ninre  uim'Ii  1m 


(h'cn  niccijil  inn.  nnd   nmre  likclv  lo  cxlcml.  a-  il   lu'diiresses  lowanl  a 


alai   roiilt.  inlo  1  he  mill   iciiinn. 


hiith  arc  liKch' 


t<i  he  attended  iiv 


a'liKM  rhaLic:    Im 


I  llial   fitim  >arcmna  i>  sn|ici1icial.  while  the  bleedini 


from  carcinmna  i>  iiku'c  lil<clv  li 


I  lie  iirtcnal. 


Carcinoma  of  the  walls  of  liie  pharynx  dill'crs  I'r 


oni  sai'coma,  even 


iiioro  dehnitelv  than  in  the  nliici'  reiiions  ol'  the  throat.     The  former 


has  the   ordinary  appeai'ance  ol    epithelium 


1.   with  hmad,   llattencd. 


prayish,    hai'd    inliltration;     the    latter,    ( 


lark    red    or    i)iir|)li.-;h    and 


pi  ilunciilated,   as   we 


11   as   sofi.      'I' 


icii    wjicn    iik'cratKin    commciiees. 


which  it  (\in'<  ipiiie  early  in  the  disease,  the  appearance  is  almost 
dia,i,Miosiic.  The  centre  id'  the  ,uray,  elevated  mass  is  depressed  and 
covered  with  yellowish-red  seium. 

i-'i'oiii  adenoma,  angioma,  etc.,  Iheie  ,-hould  he  little  didiculty 


in 


the  matter  of  diaLinosis,  as,  hesides  the  dill'ci'ence  in  clinical  symp- 
tom-  and  appearances,  these  diseases  arc  free  from  nicei'ation  and 
the  general  caelie.xia  indicative  of  the  graver  alVeclion. 

The  use  of  the  niicroscojie  slio\ild  in  any  event  render  the  diag- 
nosis inore  ceiiain.  Ki'(">nlein,  in  a  hi.-tory  of  sixty-one  cases,  says 
that  they  wei'e  all  tlat-celled  epitheliomata,  and.  fd"  these,  fifty-six 
occurred  in  men  and  only  live  in  women.  Xo  hacillus  of  cancer  lia~ 
.so   far  hccn   discovered. 

Prognosis.— This  is  always  unfavorahlc  in  cai'dimmatous  disea>i> 
of  tl  e  throat,  whetlier  situated  in  the  palate,  tonsil-,  or  pharyngeal 
wall-,  it  is,  in  fact,  a  uniformly-fatal  disease.  The  length  of  time 
the  |iatient  may  live  will  vary  fr<ini  a  few  m.inlh-  u)  (Hie  or  two  years. 
In  a  few  eases  if  operated  on  eaily  the  neoplasm  may  he  removed  and 
temimi'ary  relief  secured  for  the  patient;  hui  recurrence  almost  in- 
vnriahly  takes  place,  and  sooner  or  later  the  result  will  he  fatal. 

Treatment. --i'alliative  treatment  is  ahnut  all  that  is  advi-ahlc 
in  these  cases:  mild  washes  to  th(,'  throat  and  tlie  application  id' 
spray,'^  of  cocaine  to  relieve  tlie  pain  of  swallowing.  The  spray  of 
menthol  in  alholene.  '.'  to  5  per  cent ,  will  also  produce  a  grateful  and 
soothiuL'  etTect  upon  tln^  pharynx  and  help  to  relieve  the  excruciating 
pain  which  siumMimes  attends  the  disease.  This  is  |)ar(iciilarlv  the 
case  if  the  menthol-spray  is  applied  directly  after  the  cocaine  sohi- 

20 


i 

1 

> 

:ll 

i 

;.'     1 

'■■     \ 

i 


m 


w 


^f  -il 


;n»j 


niSEASKS    Ol-     rilK    I'llAKYXX. 


i'  ! 


tion.  It  scorns  to  have  tlio  ciroct  cf  prolonging  tlic  action  of  the 
hitter,  and  at  the  .-anie  lime  of  pn'veiiiing  the  (le[)rcssing  ell'eet  whicli 
the  cocaine  somotinies  prodnces.  Supporting  measures  in  the  most 
palalahle  form  are  also  reipiired,  for  tlu,'  ihiy.s  of  the  [lalient  frequently 
(h'|ii'nil  upon  the  hiiu'li:  n|  limr  ihiriuLi'  which  lie  i-au  parial^c  n\'  fdml 
sulliciciit    to  sustain   life. 

With  I'cgard  to  ()pciali\e  treatment,  fd  he  efl'ecUial  at  all  it  must 
he  radical  a-  \\(ll  a~  carl\  :  and  many  eases,  even  if  taken  at  the 
very  cunimcnceiucnt.  wduld  not  he  lit  >ul)ieets  for  o|)eraticin.  'I'hc 
(pie.-ii(in  of  excision  in  any  case  is  a  sei-inus  one,  and  upon  it  the  sni'- 
gi'on  must  nse  his  wisest  judgment.  Still,  cases  are  nn  I'ecoid  in 
wdiieh  the  cancerous  growth  has  hecn  euliiily  i'emii\e(l,  the  wound 
ha<  healed,  ;ind  fur  a  pi'njiinged  |iei'iod  tliei'c  has  hecn  no  return. 
Micknlicz's  case,  a  woman,  aged  (iTi.  who  had  lieeii  .-ulfeiMUg  for  six- 
teen months,  was  operateil  on  successfully  hy  an  external  lalerid 
operation;  two  and  a  half  years  later  there  was  no  relui'ii.  Dupage, 
fdllowing  Mickulic/V  mellmd  of  lateral  phaiwugntomy,  operated  suc- 
i-essfully  upon  ihi'ee  ca>e>.  whicli  ai'e  all  .-aid  tn  have  he;ii  cured. 
allluuiLih  the  intervals  Itetwcen  the  operations  niid  the  re[>oit  are  n(u 
gi\en.  In  {''errai'dV  case,  aged  Tl,  the  gi'owtli  was  i'emovt<l  from  the 
palate  hy  knife  operation,  and  fi\(>  years  laler  there  had  heeii  no  re- 

tlll'll.      'I'lioe  are   execpticill.-   to    the   LlCllcral    |-llle. 

It  may  he  laid  down  a-  a  reasonahlc  c(uielu>i(ni  that  in  all  cases 
wliei'e  the  cancei'im>  cacliex^  i  ha>  hecnme  develop( d,  radical  oper- 
ations should  not  lie  undertaken.  Cases  may  occur,  however,  in  wdiich, 
although  a  speedily  fatal  result  is  ceitr.iii,  the  malignant  mass  may  so 
ohstruct  respiration  or  (h'glulition  that  a  removal  of  part  of  it  may 
gi\'e  temporally  ea-e.  Menzes,  of  .\msterdaiii.  repents  a  case  of  this 
kind.  .\  l.o  .;(' (•ancerou>  mas<  w as  gi'ow  ing  from  the  I'iiiiit  pharyngeal 
wall,  prodiicim:  (<miplete  nasal  stenosis.  lie  removed  if  hy  (Jott- 
stein's  curette,  alldi'ding,  for  a  time,  con.plite  relief  to  the  patient. 
In  cases  of  this  kind  itperatieni  would  he  hoih  jusiillahle  and  laudahde. 

When,  on  ihc  other  hand,  caclie\ia  is  not  noticeahle,  the  growth 
is  acces^ihle,  ami  there  is  a  fair  pro>[iect  id'  eradicating  the  tumor  in 
its  entirety,  it  is  usually  advisalde  to  operate.  The  method  must  he 
governed  hy  the  cin  iim.-tances  of  the  case,  together  with  the  apti- 
tude and  experience  of  the  operator. 

If  the  intrapharyngeal  o])eratioii  can  lie  accomplished  snccess- 
fnlly,  either  hy  snare,  galvanocautery.  or  knife,  it  is  to  be  preferrerl 
to  the  larger  operation   hy  external  excision.     Still,  each  case  must 


ORO-r II AK  V N  X .      (  A]{C IN OM  A . 


3ir 


I  may 
thiV 

Ltt- 

licnt. 

Ible. 
bwth 
Ir  in 

t   1)0 

lipti- 

poss- 
Irrccl 
luist 


be  judged  on  its  own  merits,  tlie  wurk  l)eing  aceoinjili.-!ied  in  aceord- 
ancc  witli  tlic  \v('ll-('>liil)li>lied  rules  of  surgical  procedure. 

K\l('.  (uir  niii.-i  riniii  millKU'ity.  in  hi-  work  ju>t  published  dwells 
U])iin  the  diircrentiiition  w!;ich  exists  in  iliis  r;irc  disease.  Tie  say.-: 
"If  tile  earcinoiua  be  of  the  epit  h''lial  variety,  the  i;i'n\\th  is  soft,  ami 
spoiii^y  in  eliaraeter;  or,  if  of  tlie  seirrhus  variety,  it  begins  as  a  liard 
irregnhuiy-nut lined  nuiss.  Tn  oitlier  form,  early  in  the  gruwili  tin; 
nnieous-membrane  surface  is  fairly  inirmal  in  appeaiance;  but  with 
idecijitinn  this  is  entirely  lost.  The  cei'vical  gland-  are  invulve'l,  niid 
in  the  seirrhus  xai'iety  this  involvement  t.akes  place  early.  It'  the 
growth  occurs  low  down  in  the  pharynx  and  is  limited  to  the  posterior 
surl'a'c  it  is  more  often  of  the  fungoid  chaiaeter.  it  is  very  irregular 
in  outline,  and  the  surrounding  structures  are  -udllen  almost  to  the 
point  of  being  (r'demalniis.  In  huv  involvenuMii  of  the  pharynx  there 
is  not  such  marked  imjilieation  of  the  cervical  irlands."" 


I 


CIIAI'TI-.K   LVIll. 


NKl  KO.SKS  OF  IIIE  TAUCKS. 


l)rsoiii)i:i;i:n  >on.-iliility  nT  ;lic  ti'iiuinal  liliiiiK'nts  of  the  nerves 
of  tlu!  [iliaryiix  are  imt  nl'  inrici[iionl  (iccurreiir-e.  'J'licy  may  be 
divideil  iiilo  neiim-i.-  of  ^L'li.-alinii  and  iicurnsis  (if  nidtioii. 


Ill; 


1   ; 

I'   i 


N  i:i  iio'-i;-  i»i'  Si:\<Ariii\. 

Xi'iini.-i-  iif  .-('iisaliitii  may  he  jtre.-eiil  in  the  t'orin  (d'  aiia'^llie^ia, 
hyll^^a^-lhe^ia.  ni'  para-t  hc-ia.  ami  (K-ca.-innaily  a>  iieiiral.iiia.  'I'he  lir.<t 
is  (d'  \\\\\^'  mnmciit.  wilhnin  ii  i>  a.-sucaaied  with  paraly.-is,  oT  which  it 
may  he  a  sym|iliiiii.  W  hcii  (McinTiiii;-  alone  it  I'aicly  calls  U>v  Ireat- 
inont'.  I'os.-ihiy  the  administratinii  df  -li-ycliniiie  and  tlii'  apjjiicaiion 
of  ji'alvanisni  may  lie  nf  hcndit. 

ITy|)cra'.*thf~ia  and  ]iaiwsllKvsia  (d'  tlie  jihai'ynx  are  practically 
synonymnns  trrm>.  and  indicate  over-ensitiveness  of  the  miici)ns  ineni- 
hrane,  tlioniih  tlic  Ihihk  ]■  i>  ii>iially  ajiplied  to  touch,  and  the  latter 
to  the  fcclinti'  (d'  prickini:-  and  irritation  which  .sometimes  exists  with- 
out  aj)parently  adequate  cause.  This  is  ])articularly  liable  to  occur 
in  liystci'ical  wnmcn.  .\>  a  rule,  the  palate  i-  more  .sensitive  than  any 
other  part  nf  the  ihrnat.  1  have  nm-  male  ))atient.  however,  aged  35, 
who  has  |'(ir  years  bei'n  under  treatini'Ut.  u(]'  and  (ui.  for  atropliic 
rhiniti.*:  but  in  his  case  the  sensitive  i>art  is  the  base  of  the  tongue. 
He  cannot  bear  the  slightest  jiressuic  upon  it,  without  producing 
retching,  although  any  dthei'  part  of  the  ihrual  can  bo  touclied  with 
impnnily.  l-"ven  the  application  id'  ei  laine  i-  without  coiUroUing 
etl'ect;  the  e(jnsequenee  is  that  in  his  caie  the  use  nf  a  tongue- 
depressor  is  always  (mt  of  the  ipiestion.  Tn  tlic  majority  of  instances 
pharyngeal  hypera'sthesia  nwes  its  origin  to  some  local  lesion  the 
removal  of  which  woidil  relieve  the  annoying  symijloms. 

Neuralgia  of  (he  idiarynx  i-  usually  unilateral  and  may  owe  iis 
origin  either  to  a  local  nuu'bid  condition  or  to  sonu'  form  of  an;x'mia. 
Tt  is  not,  as  a  rule,  associated  with  hysteria.  IJemoval  of  any  exist- 
ing local  lesion  or  tonsillar  conendion,  together  with  the  adminis- 
tration of  systeune  tonics,  such  as  ipiinine,  iron,  arsenic,  or  -trychnine, 
would  seem  to  be  the  best  treatment. 


jilfifii 


•    I'; 


OKO-rjIAKYN  \'.       I'AHAl.VSIS    OF     llli;    FAICIIS. 


lilt) 


S|ia.-iii  (iT  the  |)liiii'3ii.\  i^  nut  n\'  iiiriLH|iitiii  m  (•nirciie.'.  IL  iiuiy 
ari.-o  I'lciii  (.'Iniiiiiuiuii  or  (I'lluma  nf  ilic  uvulii.  aruii'  iiliarviiLi'iti-^.  ap- 
plicalion  of  local  ii'vitaiiis,  ( ic.  ( 'hiu'iiii/hi  ainl  Mai^iiau  relate  cases 
arising  rroin  labcs,  wliicli  wore  al  nice  cured  liy  .-riispensioii.  'i'licy 
l)olievo  that  tlie  i)!iarynL:eal  ^pa^^lll:^  are  inlliieiuetl  by  central  or  pc- 
riplieral  lesion.-.  Spasm  of  tlie  piiarynx  is  [uoduced  I>y  liydropliohia 
and  also  by  tetanus,  lieini;'  in  eacli  ca^c  a  -yniptuni  of  sy.-temic  disea.-o. 
The  pai'l  usually  alTectcd  i.s  the  sufl  palate,  the  levalm'  palati  heinu' 
the  nin.sclc  ordinarily  insolved  in  eaj-es  oi'  chnrea  alTectcd  liy  ])haryn- 
gcal  spasm.  In  snnie  ca^es  the  con.-lrictur  mu-chs  ai'c  all  eqnaliy 
involved. 


HSMM 


le. 


UK 

le- 

•es 

le 


PAUATA'SIS    OF    'IHi;    FAUCES. 

One  of  the  most  conimnn  t'orins  df  throat;  paralysis  is  that  iii 
which  it  occnrs  as  a  sequel  to  diphtheria.  It  ha-  he.  w  known  al.-o 
to  follow  acute  lacunar  !on-illitis.  In  these"  cases  ihci'e  is  little  doidit 
that  the  disease  is  of  central  origin,  arisin^i'  from  the  cU'ects  nf  the 
toxins  of  diphtheria  upon  the  nerve-centre-,  in  tin's  aU'ection  the 
voice  a-sunies  a  quackinu'  oi-  nasal  iwani:'.  ii  liecduies  impo-sihlc  in 
some  oases  to  render  tense  the  levatni'  palati  niu-clcs  so  a-  to  close  tiio 
nasd-pharynx  fi'mn  llu'  Driiqiharynx.  ('(iiise(|iicnt  ly.  in  aUemptin;:"  to 
swalhiw,  ilie  fciiiil  will  frri|iiriil  ly  ]ia>s  into  the  vault  almve.  In  other 
instances,  the  pharynu'i'al  enn.-trictors  liavinu'  hi>|  their  )>ower  of  eon- 
traetion,  ordinary  deulnlition  becomes  imjiossibh',  and  the  patient  is 
obliLi'cd  to  force  the  food  downward  oiit  of  the  oroqiharynx  by  iillinij,' 
bis  mouth  with  llnid  and  then  aidinir  the  proci><-  by  the  compression 
of  the  oral  muscles. 

In  th(v-e  cases,  -innlar  treatment  to  that  ]M-eseribed  for  ana's- 
thesia  of  the  ]iharynx.  the  u-e  of  nerve-tonics,  and  tlu;  application  of 
elect  ricity  may  be  tried;  but  they  are  often  nnavailiiiLT.  Weeks  jtas.s 
avay  witliont  apparent  improvement;  then  the  recuperative  power 
of  Nature  slowly  asserts  itself,  and  the  normal  function  is  Liradually 
restored. 

Sometime-  paralysis  of  the  palate  accompanies  facial  paralysis. 
It  is  then   nnilateral.     Xo  special  treatment   i.-;  required. 

!Myo])athic  paralysis  occurs  in  some  morbid  condition^  of  the 
mu.=cnlar  fibres.  Whether  tliis  is  really  the  -(\Tt  of  the  lesion,  or 
whether  tlu'   ]iaralysis   of  eerfain    muscles   ari-^e-    from   an    abnormal 


1|,;  11 


ir  ! 


I 


I :  ^f 


1]2{J 


DISKASKiS    Ol'    TIIK    I'llAHYNX. 


'■  M  ■ 


condition  of  llie  pnuillor  ncrve!«  or  nervc-lilanicnts.  is  still  a  matter  of 
([Ui'Ftion.  Soniotinics  ouu  gronj)  of  niu.-^i'lcs  niiiy  bo  aireetod,  sonie- 
timos  another;   tlio  allVction  may  be  cillier  unilateral  or  bilateral. 

]'alato-glo8so-pharynj.'eal  jiaralysis  is  one  (if  the  symptoms  of 
])rogressiv(!  l)ulbar  paralysis.  Jt  arises  from  an  anivmie  condition  of 
the  mednlla.  it  is  rarely  met  with  hefore  the  age  of  forty  years.  All 
the  nerves  su].']ilying  the  muscles  of  deglutition  and  artieidation  may 
he  involved.  The  gl(issi)-]iharyngeal,  hyi)oglossal,  facial,  spimil  ac- 
cessory, and  trigeminus,  all  having  their  origin  in  the  medulla,  may 
be  alfectcd  in  this  disease.  As  a  rule,  tlie  mahuly  alfocts  the  t(Uigm; 
first,  then  the  lips,  palate,  and  pharynx. 

As  its  name  iuiplics.  it  is  progressive,  slowly  but  steadily  ad- 
vancing toward  a  fatal  issui'.  Marly  in  the  disease  there  is  indistinct- 
iH'SS  of  s])eeeli:  dyspliagia  also  is  an  early  symptom.  These  steadily 
advance  until  articulation  becomes  unintelligible  ajid  deglutition  im- 
])ossil»le.  AN'asting  and  misery  beconu'  extrenu^  and  the  patient  suc- 
cund)s. 

Acute  bulbar  ]iaralysis  nuiy  also  occur.  It  is  exceedingly  rare, 
and  dill'ers  little  from  the  ]ireceding,  except  in  the  rapidity  of  the 
progress  of  the  symptom?  and  the  speedy  termination  of  life. 

In  trcatmcni  of  either  little  can  be  done;  and  that  little  is  con- 
fined to  tlu'  relief  of  concurrent  symptoms,  based  on  the  general 
{U'inciples  of  tliera|ieuiics. 


CllAPTKR  LIX. 


FOHKHiN   liODIKS  IN  TIIK  FAUCKS. 


ONSII.l.l  IMS. 


In  (•onncclioii  with  this  suhji'd  a  wni'd  ini^lit  he  said  ahmit  the 
eoncrt'tions  or  calnireoiis  deposits  which  arc  snuictiiiics  i'oi'iiicd  within 
the  laeniiai,  or  crypts,  of  tlic  tonsils.  In  certain  inilaniniatory  condi- 
tifiup,  Avliicli  dnriiiij  middU*  aire  tend  to  in'odiicc  cdnncctive-tissiic 
liyporphisia.  the  mouths  of  tlic  eryiJls  niay  hcconic  ch)scd,  and  the  re- 
tained secretion  iii-pissated,  until  in  time  calcidus  is  lornied.  It  is 
(loubli'ul.  however,  whether  this  can  occur  without  tlie  pi'evious  do- 
])osit  within  the  crypt  of  sonic  sniall  loi-ciun  hody.  wliich.  as  in  the 
ease  of  the  rliinolith,  liecouies  tlie  nuch'us  ai'ound  which  the  con- 
cretion gradually  forms.  'J'hese  ealeuli  were  at  one  tinu'  cousidered 
to  arise  from  a  gonly  ad'eetion  of  the  pharynx.  This  theory  has 
latterly  l)cen  discarded,  as  repealed  e.xainiiuitioiis  of  the  tonsillar  cal- 
culi have  alway.s  ])ro\cd  them  to  consist  of  ])liosphate  and  ear])onate 
of  lime  instead  (d'  urates.  The  symptom-  are  similai'  to  those  of  coni- 
nu'iicing  ([uin.^y.  Sometimes  the  diagnosis  is  a  little  dillicult,  owing 
to  the  conlpletenes^:  with  which  the  foreign  Imdy  is  cuvcred.  }'a]pa- 
tion  and  probe  exannnation  should  rcnmve  iiU  douht.  Still,  instances 
have  occurred  in  which  the  coiu'retion  wa>  not  su.-pecteil.  until  it 
was  grasped  liy  the  tonsillotomi'.  'I'reatnu'iit  consists  in  I'cinoving 
tlie  calculus  hy  means  of  the  forceps,  or.  when  nece>-aiy.  incision 
with  bistoury  in  order  to  make  extracti(Hi  po^siiile.  ami  then  I'cuioval 
with  forceps  oi'  spoon.  The  use  of  a  cleansing  wa>h  would  he  all  the 
after-treatment  rei|nired. 

In  the  issue  for  dannary  T.  ISIM).  id'  the  lirilisli  Mnliral  .luiininl, 
Aitchison  TJohertson  gives  the  history  (d'  the  largi-st  tonsillar  ealcnin.s 
on  record.  It  was  shaped  somewhat  like  an  egg.  Its  greatest  leniith 
was  4.4  centimetres  ami  greatest  breadth  ;>.S  cent  imetics.  The  weisrht 
was  2(5.8  yrainmes.  The  age  of  the  ]iatient  was  .")i»  years,  ami  its 
]iresence  was  never  discovered  until  it  wa-  expelU'd  by  violent  cough- 
ing during  a  snlTocative  attack  which  occurred  about  the  middle  of 


i.Hiiii 


i 


1 


3-^; 


i>i.-i:.\m:.s  of  iiii;  i-iiakynx. 


lU- 


i, 


till'  iii.Lilit.  It  caiiu:  I'l'Diii  tlic  liulil  tiiD-il.  'I'liero  wa.-  no  liaMnnrilin;ie, 
lii:|  a  lai-c  cavily  iiiarkid  ilic  >iU'  dt  iis  I'oniiatioii.  It  was  pale  yul- 
]u\v  ill  ciiloi'.   hail  a  wonn-fati'ii  a|)[a'araiico.  and   while  fresh  hail   a 

>I  li'li'j'  (uliir  I  I'i;^.  !H1). 

]''uifi;ii;N'  i'oniKs. 

I''iiri'ii:ii  linilio  ai'r  ntlrii  Imli^rij  ill  the  iiliai'viix  rrniii  witlinni. 
Tlivy  are  vriy  ilivir.M'  in  rharaclcr,  cnnsi.>tinij;  of  siwh  siiljstancrs  as 
pieces  (if  iiH'af.  t'rau'im'iit^  ni'  lidno,  false  teelli.  liiiltnns.  coins,  pins, 
iieedli"^.  etc.  Small,  jmintcd  l)ndies  are  apt  to  heeonic  fixed  in  the 
lonsils  or  pli;iryni:eal  walls  or  about  tlu'  top  of  tlu?  larynx.  Larixer 
liodies.  riiiinil  or  sipiare  in  mil  line,  arc  more  likely  to  he  Iodised  in 
the  lo\v(-r  pharynx  or  in  one  of  the  i>yrifonn  sinuses  or  hetween  the 
tongue  and  epi,L:lottis.  Occa.-ionally  the  ell'ect  of  Xature  to  expel  the 
foreii^ii  hody  hy  spasmodic  (laiuhing  results  in  throwing  it  forcildy 
into  the  naso-ohaiviix,  where  ii  mav  either  remain  lodircd  or  he  airain 
cxpell(>d. 


11, 


I'ig.  'JO.— i;iilKHsiiir~  (■aliulus  iVoiii   iij,'lit  tonsil;    weight, 
2G.JS  i^raimiics.    Ailnal  si/c. 


h  :    ! 


Tin;  sympionis  produced  hy  i'orei,i.;n  bodies  in  the  pharynx  arc 
freipiciiily  di>ire.->in,L:-.  I  (e.ulutitinn  may  he  seriously  interfered  with 
or  e\en  suspended.  Sc\cral  years  a,i:o  1  removed  a  needle  from  the 
lower  part  of  a  woman's  pharynx  which  had  heen  lodiii'd  there  trans- 
versely for  twelve  hours,  during  which  tinn?  she  had  heen  entirely 
nnahle  to  swallow  anything,  not  even  fluids.  There  is  no  douht  in 
this  ease  that  the  inability  was  partly  voluntary,  owing  to  the  pain 
which  the  en'ort  ju'oiliieed.     Hard  substances  may  loilge  in  the  pyri- 


oiiM-i'ii  A  i!VN  \.     iiM;i;iti.\    r.itiUKS 


•3-r> 


I'niiii  siiiii.-,  ami  [irodiici'  piiiii  in  tin'  hileral  regions  of  the  lower 
plKsrynv,  as  well  as  inleilere  with  .-wallowing. 

W'Ih  11  the  foreign  body  is  located  in  the  oro-pharynx,  it  may  he 
oliserved  in  many  eases  l>y  dinet  light;  hut,  in  the  majority  of  in- 
stances, the  use  of  rcllected  light  and  a  throat-mirror  will  he  reciuired. 
In  all  doubtful  cases  the  exannnation  slunild  bo  as  thorough  as  |ios- 
sil)le,  and,  if  the  mirror  fail.-  to  rcvi-al  anything,  digital  p.\[)loration 
may  he  resorted  to.  to  make  iIk;  diagnosis  ceilain. 

The  liistory  of  the  case,  togulher  with  tlo'  syin|itnnis  niul  tlioroiigh 
inspection,  will  usually  make  the  nature  and  position  of  the  object 
clear.  When  still  in  doiibi.  ilic  ii.-c  nf  thf  sciagraph  should  remove 
all  remaining  um  riiainl  \ .  It  niu.-t  br  miieiiibered,  huwever,  that 
not  oidy  iiiay  the  pri'-eiicc  of  a  foreign  Imdy  in  the  pharynx  be  im- 
aginary, but  also  that  e\rn  iIp-  ri'mo\iil  or  expulsion  ol'  the  foreign 
liody  ina\'  be  followe(|  lu|-  wiik-  or  even  nioiith-  afterward  with  the 
iiiipir-.-i(in  in  the  mind  of  tlic  patient  thai  it  is  -^till  in  the  old  posi- 
tion. 'This  is  part  ieiilarly  likely  to  oiciir  wlun  the  subjects  are 
by-lerical   wonieii. 

Prognosis,- "This  varies  according  to  the  nature  and  position  of 
the  object.  Sharp  pieces  of  metal  or  bono  may  (hi  =erious  harm. 
They  have  been  known  to  peiielrate  the  blood-vessels  of  the  neck 
and  produce  death  by  ha'inorrliage.  In  otli(>r  in-tantes  they  have  fre- 
quently fouml  their  way  into  the  tissues  of  tln'  neck,  and  been  ex- 
tracted from  situations  far  removed  from  the  point  of  entry.  Tvarge 
bodies  have  become  impacted,  and  have  prodneed  a  fatal  result,  by 
ulcerating  through  the  ])haryngeal  walls  and  iiidiieing  pyannia. 

In  the  majority  of  case-,  however,  tliev  mav  lie  removed  with 


more  or  less  facility,  and 
pharyngeal   walls. 


\\  \\  hoiii   !eii\  iii'j  an\   -< 


rioii-  ell'eet  ii|)on  the 


Treatment. — This  consists  simply  in  removing  the  foreign  body 
as  gently  as  ]iossil)le,  and  with  a  minimum  of  injury  to  the  surround- 
ing tissues.  To  accompli-h  this,  as  a  rule,  we  need  a  good  reflected 
light,  the  throat-mirror,  and  forceps  to  suit  the  position  and  nature 
of  the  object.  The  finirer,  in  exploration  as  well  as  removal,  is  often 
of  groat  assistance.  Some  objects,  such  as  pins,  may  ho  grasped  be- 
tween the  finger  and  the  miil.  in  not  a  few  instances,  and  their  removal 
eifected.  In  some  cases  the  curette  will  be  of  service,  and  in  others 
the  snare;  while  in  still  anoflu'r  class  the  careful  insertion  of  the 
coin-catcher  or  the  umbrella-bougie  into  the  upper  part  of  the  oesoph- 
agus will  result  in  lifting  the  olij(>ci  directly  into  the  outer  air. 


ill.! 


■  'i 

■    U 


.  I 


1  (,- 

Ml 


« 


1 


;}2-i 


DISKASKS    OF    'I  UK    I'lIAKYN  X. 


After  the  removal  no  otlier  tn'iitiiu'iit  i.s  recjuireil,  except  tlie 
wariiiiii,'  to  tlie  patient  that  lor  sninr  time  the  impression  may  remain 
that  the  foreign  body  is  still  wiliiin  the  pharynx. 

Wlien  tlie  obstruetion  seriously  interfi-res  with  respiration,  and 
eannot  at  the  time  Ix'  remnved.  traeliedtniny  may  he  called  for,  resort 
being  made  to  further  ed'orts  after  the  artificial  breathing  has  been 
established. 


•r 


SHfTION  III. 


Diseases  of  the  Larynx. 


hi 

■  I  If 
.1^ 


I 


1 

u 

i! 

i 

i  i,|ji 

M 

i'i 

m 

\\' 


11 


IIIAITKK  LX, 


AN'AI'OMV  <•!•■    TlIK  I.MiVNX, 


I'ol!  till'  iiiiiiiiU'  aiialdiiiv  ol'  tlio  larynx  llif  nailti  iiiii-i  ho  le- 
rern.'d  to  tlie  doscriptioiis  ol"  iiiiiix'  t'lal)oralt'  tuxl-lxinks.  liiioii';!!, 
liowi'Scr,  (if  the  ;,M'nci.il  aiKilinny  may  l»c  !;i\rii  lu  iiidirati'  iiii|HirtaiU 
points,  \vitli(jut  till'  l\ii(iu  Ifd^i' 1)1'  uliiili  It  uiiiilil  Itc  iiu|)()ssilili'  In  in'al 
clVt'ftiially  (lioeatios  ol'  this  oriraii. 

Thi.s  cniiipjicatod  or;;aii  may  ho  ooiisidcrod  as  an  c'.\|iaii.-ioii  of 
the  trachea.  It  lii's  hoiwccii  the  hyoid  hoiio  ahove  and  tln'  liaclica 
below.  The  lowtT  phaiynx  and  the  cntiancc  to  the  (osopliauus  lie 
behind  it,  and  the  skin  and  superlic-ial  ti.ssuos  cover  it  in  front.  On 
each  si(K'  aic  the  j^rcat  vessels  and  nerves  and  it  is  eonneeted  with 
the  adjacent  i)arts  by  nniscles  and  ligaments. 

15eliind  tlie  laryn.v,  from  the  tip  (d'  the  ei)i<,dottis  to  tlie  lower  bor- 
der of  the  cricoid,  lie  the  third,  fourth,  fifth,  and  sometimes  the  sixtli 
cervical  vertebnx);  that  is,  when  the  organ  is  in  a  stationary  position. 
During  phonation  and  deglutition,  particularly  the  latter,  it  makes 
notable  excursions  in  au  upward  direction. 

The  larynx  is  the  entrance-door  to  the  lungs,  and  allows  the  freest 
passage  of  air  during  the  acts  of  in>piration  ami  expiration.  'The  other 
chief  function  of  the  larynx  is  that  of  phonation. 

'J'he  larynx  is  composed  of  five  jirincijjal  cartilages:  the  thyroid, 
the  cricoid,  the  epiglottis,  and  the  two  arytenoids.  There  are  also  four 
sup])lementary  cartilages:  the  two  of  Santorini  and  the  two  of  Wris- 
berg  (Fig.  <J7). 

The  cricoid,  or  ring,  cartilage  is  the  foundation  of  tlie  larynx. 
It  rests  directly  upon  the  trachea.  It  is  formed  like  a  seal  ring,  the 
small,  rounded,  curved  portion  being  in  front,  and  the  enlarged,  thick- 
ened, seal  division  being  beliind.  On  tlu'  upper  surface  of  the  back 
])art  are  two  large  facets  for  articulation  with  the  arytenoids,  and  on 
the  outer  portions  of  the  same  surface  two  smaller  depressions  for 
articulation  with  the  inferior  corTiua  of  the  thyroid  cartilage  (Figs. 
98  and  1)9). 

The  nnder  surface  is  attached  by  rd)rous  tissue  to  the  upper  ring 
of  the  trachea. 

(327) 


328 


DISKASKS    (>|-    TIIK    I.AUY.VX. 


T]iG  thyroid  cartilage  is  sliiold-i^liapcd,  and  fo.ms  the  hirgest  por- 
tion of  the  laryngeal  friiiiie-work.     ft  i.s  composed  of  two  .=ynimc(rical, 


_  .-.■'.ii* 


Fig.  OT.—TIic  cjirliliicriiio-.is  friiinc  nf  Mic  luiyiix,  willi  tlie  liyoid  l)oiio 
and  ligaiiiontous  aitacliiiiciits  (liroca).  .(,  llynid  bone,  li,  It,  'I'lio  grcalcr 
coiiiua  of  tho  hyoid.  C.  r.  'llic  lesser  coriiiia  of  the  liyoid.  /),  Kpiglotlis. 
/'-',  Tliyroid  eartilago.  /•',  /•'.  'Iii<.  superior  cdrnua  of  (ho  thyroid.  (/,  'I  he 
lesser  cornu  of  Ihe  (liyroid.  //.  ("ricoid  cartilafre.  1.  Thyro  epi;,rl,itlie  ]ign- 
nicr  .  2,  iryo-epifrlotUc  ligament.  ;!.  I.atx'ral  thyrohyoid  ligament.  4, 
Median  cricothyroid  ligament.  5.  Lateral  crico*liyn>i''.  ligament.  (After 
riosworth.) 


ANA  roM^  . 


32!) 


l'oiir-?i(k'(l  [ilates,  miitod  togcllicr  in  front,  at  an  aiig'lo  of  about  ninety 
(Icfrrccs  (V\ix.  ]ii(i).  'I'licy  form  the  front  and  lateral  walls  of  the 
hirvnx.  and,  o\\  inu'  to  their  staliility.  arc  a  diiot  protection  to  the  deli- 
c-!ite  >liiiilin(^  eoiilaincil  within  tlir  (W^aii.  'I  he  union  of  the  two 
|ilatrs  sei'ves  for  the  attaciinirni  d'  thr  i-i'icnthyi'nid   nimdiranc  at   iIh' 


KiiT.  !'^.  Ill"  riiii'iil.  -(Ml  inilii  lolly  ilii'dcn).  1,  Aiilcrior  porlion, 
2,  I'ostcridi'  pditimi.  3,  lii(ciii;il  -mliui',  1,  Sii]i('i  inr  circuniferetiii'.  a,  lii- 
t'ciinr  bonier.      (Al'ftT  liosw  intli.  i 

lower  iiiarLiin.  At  the  ii|i|i(i'  inai-in  nl  iiiuon  there  is  a  deep  aeute 
an.ii'le.  railed  the  thyroid  notch,  into  which  is  attaclicd  the  petiolns  of 
the  epiijlottis.  I'rojeef  i,<r  ]h  rpendic  iilarly  from  the  ])osterior  mnrnin 
<d'  eacli  ])late.  one  dnwnwnrd  and  the  other  upward,  are  two  horns,  or 


l''ig,  !l!l.-    Tlic  cricdid,  U|iiiti-  .^uila.".      1,   I.  Avticiihir  facets  fot    tlic 
iU'ytoiuiid  ciirtiiiipc  fi.     (Alter  lie^wdrtli.) 


coi'iiiia,  the  npjier  one  on  each  side  heiiiL;'  attaclicd  to  the  hyoid  hone, 
and  the  lower  one  o.i  each  side  to  tin'  cricoid  eartilaiie. 

The  arytenoids  are  little,  eone-shaped.  movahle  liodies.  standinj.; 
ereet  upon  the  lateral  facets  of  the  erie  .id  already  described.  I'lieir 
internal  faces  arc  nearly  paralhd  willi  eaeli  other.  At  their  sumnuls 
are  attached  the  two  little  eartihures  df  Santorini.     External  to  and 


330 


DISICASKS    Of    I'lIK    J.AltYNX. 


ill  Front  of  the  Juttoi,  and  situated  at  the  eoiiimenefmont  of  the  ary- 
i']ii.i;loUic  fold  are  the  little,  >-teni-like  earlihiges  of  Wrisherg  (Figs. 
JnOtt  and  lOOi). 

Tlie  epiglultis  is  a  fihrocartihigi'  and  said  lo  he  simped  like  a  leaf. 


\h' 


fl-..^^ 


Fii^.  1(10.  - 'I'lii'  <  ri(<)tli\  idid  iiiu--ili'.  Nicwcd  Miitrridily  ^l?^oca).  A, 
llyoid  1)0110.  yy,  'I  li\  idid  ciu  1  il!i<.'('.  ('.  riiynili\  (jid  iiiciiibriUio.  /),  Cricoid 
carlilajjc.  JJ,  (licotlix  roid  ni'inlnaiir.  /'.  'IiucIkii.  I,  1,  Cricothyroid 
muscle.  2,  2.  Origin  of  tlii>  musrlc  fruiii  llic  anterior  portion  and  side  of 
the  cricoid.  .'?,  .T.  Tii-ritioii  into  ijic  lower  hordci  of  (he  thyroid.  (After 
Jioswortii.) 


ANATOMY. 


'6'3\ 


■y- 


It  varich  iiinrc  in  I'miii  than  any  uiIkt  nr^an  nl'  the  \>in\\\  iml  cvni 
C'xchi(lin<r  tlif  nll^(^  h  slainis  iinniciliatcly  aliovc  the  tliyroiil,  with 
its  (ipcii  i'acc  hackwaril.  ami  is  atladn'il  hy  ii>  pedicle  m-  petioliis  t(i 
the  snperiur  nntch  of  the  thyroid. 

As  !i  ride,  the  e|iiL;|niti-  ((eenpies  nmie  (ir  less  of  ii  vertical  po.-i- 
lion.  The  anterioj-  -nil'ac!.'  i>  e(in\e\.  oi'  somewhat  sadille-sliapod  I'roin 
side  to  side,  and  eoiieave  j'l'oni  aliose  ihiwnwai'd.  These  outline-  vary 
in  ditiei'ent  (■ase>.  -ind  in  extienie  (•a>e.-  may  even  he  the  re\er-e  ,,f  i\\,- 
ordinary  rnje.     The  tio-ieiior  >nil'aee  i>  >liL;hllv  concave  from  side  to 


i<'.     IIM)(/. 


I'ii:.   Inn'). 


Fif,'.  lOlla.  Till'  \(iirfli(i\,  <ir  lMr_\ti\,  -^rcii  iiiim  lirhiiiil.  1,  li,  Itin^' 
<':utilii'.'('.  ."i,  4,  I'viiiinid  imum  Ic  .'>  mik!  (i.  shield.  7  ami  S,  'riiii^^uc'-ljoiic. 
1)  ,111(1  \'l.  (  art  11  ;i ;,'('«  of  Santoilni.  lo  and  I.'!,  t  artilaL'is  of  W'l  i>l)cr<.'.  II. 
14,  1;'),  l.id.  I(i,  WiiKlpipi'.  17,  (  ii>liioii  of  \\\r  lid.  IS  and  lit,  Hack  riiif,' 
jyyriiinid  nnwclc--.  20,  21  and  22,  2:{,  (  cinst  i  ii  lurs  (jf  the  vcstilmli'.  (Alter 
I.cniio.v   l!i(i\\n('.i 

V\^.  10U6. — N'ii'w  of  the  voicchox,  or  larynx,  cut  o|]cii  from  hcliiiid. 
1,  2,  \Uurr  cartilafic  ■"{,  4,  I'yrainid  muscle.  ,')  and  (i,  X'ocal  li^^ameiil^. 
5,  (J,  7,  8,  EntraiK'ca  to  the  pockets.  7  and  8,  Poiket  lij;aiiients.  !),  10, 
Cartilapes  of  Sautoriiii.  11  and  12,  ('artilajres  of  W'rislieifj.  11,  12  and 
1.'},  14.  Ary(']ii<;lottiL'  foULs.  15,  l.id.  10,  Windpipe.  17,  Cushion  of  the 
lid.     IS  and    Id.  I'rop  curtilajres.      (After   Lennox   Hrowiie.) 

31  A. 


I  1 


m^ 


;53-.' 


IHSKASKS    or    Tin;    LAUYNX. 


side,  iiml  in  sdinc  instnnccs  deeply  (■diiciive.  like  tlie  loim  diiiiiieter  of 
llie  hidt'-sectioii  of  11  lljittciicd  (ul)c.  lictwccn  tlic^e  two  every  variety 
(if  rmiiiiition  may  he  IoiiikI.  the  two  sides  in  each  ease  lieiii;:-.  id'  course, 
syimnetrieal  ( l-'iir.  l(»l ). 

The  e|ii,ul(ptlis  is  atlaehed  to  the  inner  ^ur^aee  (d'  the  iKiteli  of  the 


¥]<:.  lol.  ']  lie  iir_\  teiKiiil  Mill]  ]iesttii<ii-  rri<  ii;nyt('iiiM<l  imiaclos 
iBrocal.  .1.  Ilyoid  Imiic.  /}.  /{,  I'ostcrinr  Ixmlcr  of  llic  thyroid.  ('.  Vo>i- 
tcri<ir  fiKL'  of  cricoid.  /).  />.  I'oxli  rjor  ImikIci-  of  the  iirvtc  old.  /■;.  Kpi- 
^'lotti>.  /•'.  /■',  Arycpiylottic  folds,  tl.  Trachea.  1.  .Arytenoid  nmscle.  2,  3, 
Oblique  films  of  same.  4.  4.  Cricoarytenoid  posterior  muscles.  T),  5,  Their 
insertion  in  the  outer  aiifjle  of  the  lias<.  of  the  arytenoid  cartilage.  (After 
JJoswortli.) 


ANATOMY. 


3;?;? 


thyroid  l)y  a  firm  hand  oi'  (.'iastic  tissue;  ulicii  iinniiincnt.  it  is  cnhcd 
the  cushion  of  tho  epiglottis.  'I'hc  upper  margin  (d'  this  organ  rises 
al)Ove  the  liase  of  the  tongue,  to  which  it  is  attaclied  in  the  Iroiit  and 
the  two  sides  hy  the  gh)sso-e])ighitlie  UAt\<  nf  mucous  jueudiraiu'. 

In  structure  the  thyroid,  cricoid,  and  aryti'ni)i<i  caitihiges  are 
liyaiiiu',  and  in  ohl  age  liave  a  tench'ucy  tn  cahil'y.  'i'lte  o|iigh)ttis  and 
tlie  cartihigcs  ol'  Siinlorini  and  Wrisherg  are  I'drmed  ot  llhrocarlilage, 
ami  show  no  ieii(h'iic\   to  calcilicatidii. 

The  ligaments  n{'  the  larynx  are  (I)  cxtrin-ic-.  (".')  iiiti'in-ic.  (;>) 
mixed.  There  ni'e  llii'ee  ihyrdhyoid  ligament>:  the  mc<liiiii  and  the 
two  lateral.  The  median  one  i~  a  memiii'ane  (if  ela-tic  tis-ue,  attached 
to  the  posteriiir  Imi'dcr  nf  the  hyoid  hone  ahove  anil  the  upper  margin 
of  the  thyroid  cartilage  iielow.  The  two  lateral  thyrohyoid  ligaments 
are  cylindi'ical  masses  of  lihro-clast  ic  tis>uc.  couuccting  the  superior 
(■(U'lina  of  the  ihyi'oid  cartilage  with  the  grcatci'  corniia  of  the  hyoid 
hone,  r.etwcen  these  ligaments  and  the  central  mcudu-ane  theie  is  a 
thin  layer  of  (ihroiis  tissue.  The  cricotracheal  liganu'Ut  is  a  liand  i>\' 
tilii-o-elastic  tissue  connecting  the  lowci-  hordei'  of  the  cricoid  to  tho 
upper  ring  of  the  trachea. 

The  intrinsic  ligaments  arc  the  cricothyroid,  the  cricoarytenoid, 
the  su])eri(ir  thyroaryteuoi<l,  and  the  inferior  thyidarytenoid  oi-  vocal 
cords. 

'J"he  cricothyroid  is  a  hand  of  elastic  menduane  i-oni\ccting  the 
two  cartilages  at  the  cricothyroid  notch,  and  can  lie  felt  in  front  (d' 
the  neck  just  helow  tho  prominence  known  as  Adam's  apple. 

Tho  cricoarytenoid  ligaments  are  capsular,  ^utfounding  the  crico- 
arytenoid joints  (Ui  eith(>r  side. 

The  superior  thyroarytenoid  liganu'iits  form  the  \entric  iilar  hands, 
or  false  cords.  • 

The  infei'iiu'  thyroarytenoid  liganu'Uts.  or  tnu'  vocal  conls.  are 
tho  most  essential  and  important  structures  of  the  larynx.  They  are 
formed  of  strong  hands  of  ycdlow.  elastic  tis-ue.  They  extend  \'vou\ 
the  inner  surface  (d'  the  thyroid  angle  directly  hackward  to  the  )H'o- 
cessus  vocalis.  oi'  the  projc(tinir  angles  i\\'  the  arytenoid.-,  flach  vocal 
cord  is  insertetl  as  a  single  haml  at  it-  anterim'  c\irenuty.  This  splits 
up  into  three  hands  as  it  extends  hackward.  Tlu'  first  is  inserted  into 
the  vocal  proc(>ss  of  the  arytenoid,  the  second  is  iuM'ited  iido  the  ante- 
rior face  of  the  «ame  lartilagc  as  higii  uj)  as  the  ventricular  hand,  and 
the  third  is  inserted  into  the  cricoarytenoid  capsular  ligament.  A 
cross-section  of  the  vocal  cord  shows  that  it  is  trianiridar.  the  api^x,  or 


;{l^^ 


m 


^ 


331 


DISKASKS    DK     I'lIK    l.AUV.NX. 


Iponlcr-lijie,  lu.'iiig  tunii'd  toward  its  I'ellow  of  tlie  opposite  side  (Fig. 

In  \ho  adult  male  the  vocal  i'()rd  has  an  average  length  nf  '^  ', '„ 
con  timet  res  and  in  thea<lull  female  1  ■\\  oentimetres.  The  vocal  cords 
are  covered  with  iniicoua  jnenibrane,  and  the  lihres  ot  the  thyro- 
arytenoid mns(  Ic  unite  with  their  onter  margins,  making  a  large  ])or- 
tion  of  their  >uli-liince. 

'I'lie  (iiily  luixed  ligament  is  (he  epiglnttic.  ((insisting  of  two  ])()r- 
tions,  the  outer  and  the  inner,  'i'he  onter  connects  the  epiglottis  with 
the  root  of  the  tongue  and  the  hyoid  hone.     The  inner,  or  thyroe]ii- 


r     I: 


Fig.  102.— Side-view  (it  the  hii\ii\,  sIkjw  iiij,'  Uie  IiUeridr.  tlie  ri^'lil 
plato  of  llie  tlyi'did  lieiii^f 'I'eiiKived.  1.  2,  Ai\  U  iKiid  eiiitihijfcs.  ;{,  ■'!, 
ri(H'e.s.si  Vdeale;^  of  tlie  arytenoids.  4,  rroce.ssus  iinisiuliis  of  tlie  right  aryl- 
onoid.  i").  Ipiier  liorder  of  eiicoid.  ;i,  .'!,  0,  \'oeal  ci/iib.  7,  Faeel  for 
artieuhitioii  of  the  tliyroid  v\itii  the  ciieoid.  S,  Left  plato  of  ilie  thyroid. 
!),  J.efL  siii)eri(ir  cormi  of  thyroid.  lU,  Cricoid  cartilage.  11,  Trachea. 
(After  Lennox   Hrowne.) 

glottic,  ligament  connccls  the  lower  end  of  the  epiglottis  witli  tlic 
thyroid. 

Between  tlie  cartilages  and  the  nnicons  mendjrane  there  is  a  con- 
tinuous layer  of  elastic  tissue,  giving  resiliency  as  well  as  smoothness 
to  the  motions  of  the  various  parts. 

The  articnlations  of  the  larvnx  are  the  cricothyroid,  cricoarvto- 


Ir    ?    I: 

I' ; 


ANAIOMV. 


n 


ho 
1)11- 

Ite- 


iKiid,  iiiid  tile  Saiildrini  nrvti'iioiil.  'I'lioc  jninl-  arf  |iiii\  idcd  with 
articular  (■artihijros.  syiiovial  mciiiliifiiics,  and  cajtsiihir  ligaments,  and 
the  iiiDvc'Uiciit.s  pri'^cnt  arc  tliusc  n|'  tlcxion  and  cxloiisioii. 

'I'lie  larvnx  is  supplied  witii  tlin'c  sets  ol'  iniisclcs.  1.  'I'lic  crim- 
tlivididci  in  ri'oiil.  (■oniicctini;'  lln'  Idwci'  Ijoi'dcr  of  tln'  thyroid  with  tlic 
cricoid.  '2.  '\'\\v  (■i'icoai'vl('iioi(h'i  ])ostici,  or  alMhuiors  of  the  vocal 
cords.  .').  The  cricoaryteiioidei  laterales.  or  addiictois  of  the  cords. — 
tlie  thyroarytennidci  and  the  nrytenoidcus.  Of  the  latter  yroiip  the 
cricoaryteiioidei  laterales  and  the  arytenoidcits  arc  the  adductors.  'I'he 
cricothyroidei  make  teii^e  and  elongate  the  vocal  cords,  while  the  thyro- 
arytenoidei  relax  and  shoiieit  them.  ISesidcs  these,  there  arc  a  num- 
ber of  smaller  museh's  which  help  tt)  adjust  the  glottis  to  the  vari(Uis 
positions  ret[uircd  in  the  ad  of  vocalization  (Kig.  KM). 

.\l)ove  and  external  to  the  trui^  vocal  cords  and  hctwceii  tlicm 
and  the  ventricular  hands  there  is  situated  lui  each  >idc  an  elliptical 
fossa,  or  fissure,  extending  nearly  the  w  Imlc  Icngt  h  of  t  fie  cords,  'i'hese 
are  called  the  ventricles  of  the  larynx,  m  ventricles  of  ^rorgagni,  after 
tlieir  discoverer.  In  the  anterior  end  of  cadi  there  i<  found  a  little 
pouch-liko  cavity,  called  the  saceulus  laryiigis. 

The  arteries  of  the  larynx  are  dcriveil  froni  hranches  of  the  supe- 
rior and  inferior  thyroid  arteries.  These  laryngeal  hranches  are  diviih'd 
into  two  sets,  the  anterior  and  the  ])osteri(U',  the  former  consisting  of 
hranches  from  the  thyroiil  ojily.  The  vein-  are  similar  in  their  ar- 
rangement to  the  arteries.  They  anastomose  with  tlic  veins  of  the  thy- 
roid, the  tongue,  and  the  trachea,  and  they  lermiuate  in  the  inlerual 
jugular. 

The  lymphatics  .(re  supjilicd  aluindantly  to  the  uuicou-;  nieiii- 
hrane.  arranged  as  a  thick  net-work.  The  lymphatic  capillaries  unite 
to  form  trunks  on  eitlier  side  of  the  larynx:  two  ahove  the  ventricular 
hands  and  two  helow  the  cricoiil.  At  the  interarytenoid  commissure 
tlie  lymphatics  are  so  ahundant  as  to  form  a  distinct  tliiekening,  called 
the  laryngeal  tonsil,  .\lthouuh  the  lymphatic  supply  to  the  iiim-ous 
memlirane  oi'  the  larynx  is  so  ahundant,  the  cartilages,  muscles,  and 
ligaments  arc  said  to  he  entirely  without  lymiihatie  vesscN. 

The  nervous  supply  is  diTived  fnmi  the  superior  and  inferior,  or 
recurrent  laryngeal  nerves,  'i'lie  former  is  the  sen-ory  nerve  of  the 
larynx,  derived  from  the  pniMimogastic,  the  lattiM'  is  exclu.-ively  motor. 

The  mucous  menihraiie  of  the  larynx  is  supplied  with  both  tes- 
sellated and  ciliated  epithelium.  It  is  contiiUKUi-;  with  the  ]tliarynx 
above  and  the  trachea  helow.     The  lower  larynx  up  to  thi'  ventricular 


I    '   -■  i 


n3() 


DISEASKS    <)1'   TIIK    l.AItVW. 


Iiiiiuls.  uitli  tlif  except idii  (if  the  voeiil  cords,  is  covered  with  cnliimiiar 
<iliiited  epitheliiiiu.  'I'his  extends  upward  over  tlie  iiitenirvteiioid  coiii- 
iiiisstire.  and  also  ovei-  tiie  lower  iiall'  of  the  jntsterior  siii'face  (d'  the 
o])i^loltis.  All  the  rest  of  the  larviiu^'al  inucoiis  iiieiiihiiiiic  is  supplied 
with  tesse!late<l  or  S(|uaiiious  epithelium. 

'I'he  liiiiui;'  uieinhiaue  is  also  richlv  supplied  with  nniriparous 
•ilands,  |iartieularly  the  posterior  surface  (d'  the  epi;:lottis  and  the  arv- 
epiiilottie  folds. 

The  inner  larvux  is  sometimes  divideil  into  three  -ection-:  the 
upper,  or  tuhulai',  from  the  epii^lottis  to  the  veiiti'icidar  hau(l>;  the 
<'enlial,  hounded  hy  the  veuti'icular  hands  al)ove  and  the  vocal  cords 
helnw:  ami  the  infci'ior  laryuiical.  fidui  the  cords  to  the  lower  mar^irin 
lo  t  he  ci'icoid. 


n 


iti 


CilAl'I'KK   I.Xl. 


1'HVsi()I.(h;v  hi-  iiik  i.ai;vnx. 


'J'liK  liirviix  |i(i.->(,>s(.'s  twii  liiiu-ti(iii>:  nnr  in  ri'>|iiriitinu;  (lie  oiIht 
in  ])li(iniiti(iii. 

The  riiiictiiiii  dl'  llic  liiiviix  ill  n-piriit  inii  i>  to  permit  tlie  free 
jiassajrc  iil'  iiir  iiilo  lln'  liiims  diiriiiL;'  iii-|Mriil  imi.  'I'lic  I  licmy  iiciu'rallv 
jH'cc'plcd  has  liccii  that,  diirinu'  t'\|iiratiiiii,  the  air  |)a»iii,u  Diit  throtiixh 
thi'  jihittis  lorccs  the  vocal  curds  dpcii  uithdiit  any  iiiiix-iilar  cllnrt  nf 
tlio  hirvnx  Ix'iiij^'  rcqiiiri'd,  hiil  that.  (liiiiiiL:  iii>pirat  inii.  the  vdcal  cdi'ds 
act  like  a  valve  and  wniild  chi-e  Init  im-  the  pu-ierinr  ericdarvlennid 
muscles-  -the  ah(liiet(ir,-.  which  npen  thi'  Liateway  ami  permit  the  air 
to  (.'liter.  'I'lie  (•()iise(|iieiice  is  tiiat  the  pdsitiiiii  i<\'  the  cdi'd^  ill  expira- 
tion is  simply  passive,  while  in  iiispiratidn  it  i>  active,  heiie.:'  cdiilrdlled 
liy  an  impul-e  I'l'diii  the  rc-piratory  centre,  the  chink  diiriiii:-  the  latter 
act   hein^'  always  the  wider  nf  the  two. 

Iiccciit  t'xteiisive  iiivcstiualidn-.  \,\  Sir  l-'eli\  Seiiidn  lime  thrown 
doiilit  upon  tlio  correctne>s  <d'  this  theory,  lie  claim.-  that,  in  a  lar.^e 
nil  in  her  of  personal  examinat  ions  of  laryiiLics  diniiiu'  the  act  id'  hreath- 
ini:'.  lit'  has  rdiiiid  ahsdiiitely  im  chani^e  in  the  pd>itidii  of  the  coriU 
dtirinii^  that  act.  lie  allirms  that  they  ~impl\  dcciipy  the  position  id' 
com|)lete  miisciilar  rest,  the  width  of  the  chink  of  the  larynx  heint,^ 
prccist'ly  the  same  diirinii'  insjiiratioii  a,-  expiration. 

My  own  oxaininations  of  larynu■(•^  made  .-iiice  Semon  so  clearly 
ex|)ri'ssc'<l  his  views  have  vindicated  hi>  position,  and  I  lielieve  that  the 
eomdnsion  he  arrived  at  is  physioloLjically  correct.  The  dilliciilly  i- 
that  almost  any  one.  while  haviiiL;  hi.~  larynx  examined,  will  iiiicoii- 
scioiisly  use  iindiie  etl'ort  dnrin,ii-  the  ait  of  in-piration.  r.ul  let  the 
observer  Avait  until  rcsjjiratioii  has  heconie  pa.-.~ive.  and  he  will  liml 
tliat  tilt-  vocal  {■nvi]<  remain  niotionles>  dnriiiir  hoth  in.-pirat  ion  and 
expiration.  'I'lie  sliiihtest  inspiratory  elloit.  however,  will  piddnec  con- 
traction of  the  ahtliictor  muscles,  and.  in  my  experience,  the  uieatcr 
the  ell'ort,  invariahly.  the  wider  will  liecome  the  chink. 

If  tliis  is  the  true  condition,  the  val\e-tlieoiy  of  the  position  of 
the  vocal  eords  during-  inspiration  iiuist  he  erroneous,  while  the  seem- 

(■>•> "  ) 


!    J 


:iM,s 


IHsi-;  \>i;s  or    i m;   i.au^  v\. 


in;:!)  iimrr  rcjiMniiililc  (,i\r.  that  tlir  iHP>iiinri  of  iIk-c  hodics  (liiritif 
ins|iiiiilinii  iis  well  jis  cxiiiiiitinii  i>  of  a  purely  iiiissivc  cliiiractcr,  is 
|ii'ol)alil\   cdiTcci    ( l-'in-.    I  (i;;  I, 

111''    |'M'|icf    |i(  I  Inlliiailrc    (,r    till'    fllllclioll    of    tllf    liiiviix    (liiriii;; 

|'li"ii:ii""i  ili|i(ii(U  (III  the  lAiciit  jiikI  iifciiriicy  of  tin'  vnhiiitiirv  ci.n- 
•'■"I  "!'  'Ii''  \'"iii  (Old-  (liiriii-  ('Xiiiratioii.  Th. -c  or-aii.-  iirc  driiuti 
I'll"  iho  |io>itioii  of  a  iiarrou-  iliiiik  hy  the  addii.ip.r  and  llic  tensor 
III"-''!' ~--  iiiid  llieii  throw  n  into  soiioroii^  viliialioii.-  \>\  forciiiii-  the  air 
"•''  ''Npiialioii  ihroii-li  th(iii.  It  i<  thu.-  >eeii  llial  the  function  of 
re.-|iiration  is  really  one  of  in-|.iialioii,  while  jihonalion  is  purely  one 
(d'  expiration  (  Iml:'.   I'i  I  ). 

As  said  hefore.  the  only  ahdndor  mu-ile-  ,,{  the  lar\i!\.  or  tliosi> 
\\hi(di  expand  the  i:lolti>.  are  the  po>terioi'  eric  arx  letmid. 


Fir;-.  l(i:!.     'llie  linyiifrescoi.ic  im-  Fij:.  KM.-     Th,.  l;n-vn<;(i-i  (i).ic  im- 

ajre  (liniiifr  rcspiiiilioii.     i  .Mter  Hes-  :il'c  (liiriii<r  plieiMt  i-m.     i.XtOr  lids- 

"orlli.)  Weltll.l 


"'I  ill*'  iilher  hand,  ilie  niii--ile>  w  ho>e  >peeial  dntv  it  i<  to  addiict 
llie  vocal  cords,  or  dose  the  j:lottis  for  ,uir|)oscs  of  ]ilionali(Ui.  are  the 
lateral  cricoarytenoid  and  the  iiiteraryteiioid.  The  former  pulls  foi'- 
ward  (he  outer  aiiiile  of  the  Ikhc  of  ilie  arytenoid  carlila-e.  rolatin-- 
inward  the  vocal  [irocess  to  which  the  vocal  cord  is  atta(  lied,  while  the 
interarytciioidcus  pulls  into  apposition  the  arvteiioid  cartilaLics.  l''or 
finer  adjustnieut  (d'  the  cords,  the  thyroarytenoid,  heini:  attached  as  it 
is  to  tlie  whole  length  (d'the  outer  l)order  of  the  cord,  hv  its  hodily  pres- 
ence -rives  firmness  as  well  as  increased  tension,  the  latter  hciiiir  aided 
hv  the  action  of  the  cricothvroid. 


i'il\  >it)i,()(;Y. 


3:u> 


[let 

he 

hi'- 

111  ;i- 
he 

|or 
it 


In  the  Inwcr  tdiics  llif  Inn  ii\  iiuivi's  downwaifl  to  n  Imvrr  lovcl  in 
llio  tliniiit.  and  in  the  hi;.dit'r  tones  tn  a  lii;,'l>(M'  \v\f\. 

'I'lic  atli'iliiitos  of  the  voice  arc  pitcli,  intensity,  and  ([uality. 

'Pile  jtitcli  depends  upon  the  nniiiiier  of  vilnalion-  of  I  lie  viual 
cords,  dnrlni;  a  .iii\cn  liiiu'.  in  pioduciiiir  i||,.  (mK  ,  'I'lio  tii^hter  the 
tension,  tlie  f^reater  the  niiinlicr  of  \  ibral  ions  and  the  higher  tlie  pili  li. 

'I'he  intensity  depend-  upon  t!n>  force  of  the  expiratory  elTorl. 

'I'hc  (|nality  dc|ieiids  u]»on  tlie  cninhincd  inlliicnces  of  llic  whole 
vocal  apparatus,  ineliHlinir  larynx,  pharynx,  nose,  and  accessory  sinnsey. 

l'"or  a  further  account  of  the  |)liysioh\i;y  of  the  larynx,  particnlarly 
in  rcf^artl  to  phonal  ion  and  vocalization,  the  reader  i-  airain  referred  to 
niore  elidxirate  works  upon  the  suliject. 

'i\i  perform  these  functions  noririall\  the  \ocal  cords,  as  well  a.- 
the  nuiscles.  niiL-i  he  in  a  healthy  condition.  Mvon  sliiflit  congestion 
of  tlie  mucous  nieinhranc.  particularly  of  the  cords,  may  impair  their 
vihration  and  pindiice  weakness  as  well  hoarsem^ss  oi  the  voice.  When 
the  symjitoms  are  more  severe,  the  cause,  of  necessity,  must  bo  more 
serious,  and,  wlnMi  neoplasms  occur,  respiration  may  he  \ery  seriously 
interferid  with,  and  the  voice  in  many  instances  destroyed. 


i 


('ii.\i"ii:i{  i.xii. 


l,.\l!^  \(i(»s(  (\\'\. 

'I'lii-;  |iriin'i|)l('-  (iT  liir\  ii,L;nscii|iic  rxiiiiiiiiiitioii  ;iir  the  -iiiiic  ;i-  llm^c 
of  cMiiiiiiiiilidii  of  llic  |)(>>i -)iliarvii.\.  'I'lif  uses  of  llic  ln'iid-iiiii  ini-  ami 
rt'llcclcil  li^lil  iii'c  till'  >iiiin',  wliilc  llic  (liU'i'ii'iicc  ill  llic  1  lirniil-iiiiri'iii' 
is  iiK'i'cly  (llic  III'  (liaiiicliT.  llic  ciii-iihir  face  (if  llic  lar\  ii.L;cal  iiiirrdr 
Itciiii;'  niiicli  larger  than  llic  niic  ic(|iiii'c(|  |'(ir  |)(i>l-rliiiial  c\aiiiiiiati<iiis 
(l'"i;:-.  in.')).  'I'lic  rcllcclcd  |in|ii  .-.IkhiIiI  lie  placed  in  a  daik  (.Hinicr,  with 
as  little  a>  |Mis>ili|c  (if  the  (irdiiiarv  -miliulil   |irc-ciil. 

ill   c\aiiiiiiiiii^'  the   larviix.  after  waiiiiiiiL;   llie   iiiiri'di'  tn  a   Id i- 

tciii|ierat  lire  in  the  iiiaiiiier  and  fdi'  the  rea^dns  already  dcHurilx'd,  the 
|ialieiil   i.-  directed  Id  take  lidid  df  the  tdiiu'iie  with  a  iia|ikin  and  draw 


l''ij,'.   1(1").      I.ai  \  iij;ciil  Miicl  |in»i  I  iiiii(;-.in|iic  i.iiniii-. 


I  • 


i:i<H. 


it  ii'cnlly  (int.  'I"hc  inirrdf  is  |ilace(|  a,L;aiii>l  the  xift  palate  pro-iiiL;' 
iho  n\iila  lii^hlly  in  an  upward  and  liaekward  directidii.  and.  other 
thiti.iis  heiiiii  c(jnal.  the  vision  of  the  laiviix  i<  a(  once  dhtaiiied  (  I'iu. 
Jim;). 

.\lthdiiL;'h  tlic  directions  arc  sinipic,  it  usually  re(|uire>  a  little 
practice,  as  well  as  trainiiii;-  of  the  patient  td  the  ii-c  df  tlic  in-tniniciit 
to  accdinplish  the  end   in  view. 

I'"irsi  witli  rcLzard  to  liohiinu-  the  foii;inc.  It  is  usnally  tau^^Iit  tliat 
the  hiryn^dhiiiist  shoidd  liold  it  himself  with  his  left  hand,  while  lie 
liolds  the  mirror  liu'litly  lielwccii  the  liniicrs  of  his  riiiht.  Init  that  in 
some  eases  tlie  patient  may  lie  allowed  to  hold  it  himself.  Peixmally. 
I  believe  the  ojiposito  slioiild  he  the  rule.  I'ractically.  I  never  liold 
tlie  ]iatieiit"s  tonsriie,  l)ut  invariably  diicct  the  patient  to  do  it.  lie  can 
do  it  just  as  well  as  tlie  operator,  who  then  alwavs  has  bis  other  band 
(3-JO) 


l..\U\  StiOX  Dl'V, 


;!»i 


lit  liltcrtv;  lit  till'  siiiiu'  tiiiir  it  iiiemi^o  the  cniiliilcncc  nl'  llie  piitii'iit, 
who  IVt'ls  tliiit  lio  liiiii.-cll'  is  lu'lpiii^f  In  <!<>  the  \\«>ik 

Soiiictiiiu'-.  lidwcvcr.  iiotwithsliiiiiliii^   iIk'  tramiii^   \m'  '/\\r  llu' 
piitifiit.  till'  liiill  nl'  the  liin^iiii'  riM',-  so  lii;:ii  llmt  it  (lirfctl\   iiitci  \riU'S 


l''i^.    |(Hi.     'I'lic  liirv  njifiil  iiiirnir  in  iMi>ili(m   ((  uliciii    when   lii'lil   li> 
lilt    Icl'l  liaiid.     I  Kidiii  ){ii>\v(irlli.i 


iiml  jircvciits  a  )ii'ii|ht  visimi  df  tliv  laiviix.  In  tlioc  (iiM's.  while  tlic 
patient  ^tusiis  the  tdiiuuc,  thr  cxaiiiiiiiT  can  hnhl  it  ihuvn  with  thf 
(U'pres-sor  lirjil  in  ttnv  iiaiid.  wliilc  he  n>c>  thr  tliriiat-niirrni'  wilii  the 
other. 

Xot  iiil'riHini'iitl.v  tlic  ]ialali'  is  si-nsitivi'  to  pn'ssurc.  and  rotcliin.i; 


;M'J 


lil^-KAhKS    OF     I'lIK     I.AIiVNX. 


iircui-  cM  aiicinpt iiiL;'  I"  iisf  (lie  luirroi'.  I'liiiriit  pcr.-cvci'iiiicc  will 
iisiiiilly  ii\('ic(]|iic  this.  If  imi.  ;i  soliitiuii  of  cdcairic  or  I'liciiinr  iipplicv] 
t(i  ihc  I'iiiici.-  will  (ii'tcii  ailiiy  the  liypiTfiL'ii.si' iveiK'.-is  of  tlit'  ])aris. 

r>y  iii-t  lui-linu:"  tin;  [tnticiil  lo  hold  the  lioiiil  Iia.-kwiu'd  iUiil  lo 
ln'ciillu'  i|iii('ily,  the  vocal  cords  will  he  >ccii  ii:;  Iway  liclwccii  aiidiic- 
lioii  and  addiici  imi.  Ilclow  ihc  i^loltis  the  i'iiiL;'s  oi'  the  ti'i'.clu'a  cAii  he 
observed,  and,  in  Mime  instances,  the  whole  !eii<:lh  of  ilie  anterior  wall  ' 
of  the  wind-pipe,  down  to  the  hirnreatiiui  of  the  hi'dticiiial  tidies,  is 
brou,<;ht.  into  view. 

{•"of  tlu'  oh>ei'\er  lo  soe  (he  vocal  cord~  distiiicily.  and  to  hrini;- 
thcMi  in  line  parallel  with  eaeli  otlicr.  the  patient  -'  >uld  -lowly  sound 
the  won!  '"all."  To  ohtaiii  a  ^till  better  view,  the  lone  "ee,"  having 
a  higbei'  pitch,  shoidd  be  attcnipteil.  Tin'  ejiii:lott  is  will  then  be  more 
erect,  as  the  larvn.x  lias  attained  by  the  elVort  a  sliglitly-bigher  po.si- 
tidii:  hnt.  111  ibis  instance,  as  the  hasi'  (d'  Ilie  tontine  rises  with  it.  the 
use  (d'  the  tonuiie-depi'cssor.  a.-  well  as  traction,  may  |io-sibly  be  rc- 
(plired. 

The  p(i>iiion  of  the  epiirlottis  sometimes  serimi-ly  interferes  with 
a  good  view  of  the  larynv.  Instead  of  standing:'  erect,  it  iiiav  lean  per- 
niaiieiitiy  backward,  oii-t  riietiim'  the  vision,  or  it  may  lie  curled  tijion 
itself  >o  as  to  prevent  dii'cci  light  froui  being  thrown  upon  tiie  vocal 
eords.  l-"\(n  tlicM'  dilliciilties  may  in  most  instanees  be  overcome  bv 
the  conibine(i  elVoris  (d'  throwing:'  the  head  back,  using  a  very  high  tone 
of  "c  ,"  drawing  out  the  tiuiLiiic.  and  at  the  same  time  depressing  it. 

Iii>lrumeiits  have  been  devi-ed  to  draw  fiu'ward  the  epiglottis  in 
e.xlrenie  cases,  hut  they  will  very  rarely  be  reipiired. 

In  one  extreme  case'  I  found  the  epiglottis  long  and  narrow,  pro- 
jecting hofixoiitally  iia>k\vai'il  and  ]ires>ing  against  the  post-])harynx, 
the  jiaticiit  breathing  up  through  the  narrow  slits  at  the  sides.  To 
relieve  the  catarrhal  and  hoarse  condition  it  produeed,  I.  removed  a 
(liiarlcr  df  an  imdi  fr(un  the  end  of  the  organ  and  so  left  a  permanent 
chink.  Mveii  then,  however,  the  \(.cal  c(U'd~  could  not  be  distinctly 
seen. 

When  the  toii-ils  are  very  large  vision  may  be  obstructed;  but 
the  use  of  a  small  mirror  may  still  reinh'r  the  larynx  visilde.  An 
elongated  uvula,  while  it  may  seriously  interfere  wiih  the  jtost-nasat 
examination,  does  not  alTeet  examinatidii  (d'  the  larviiv. 

On  examining  tin    larynx  with  the  larvngeal  nii.'ror.  the  picture 

'  Transactidns  of  (lie  Tati  Aniciicaii  ^rciliial  ( '(nifrM  s«,  Washington,  ISO."?. 
Section  i^f  I.arvnirfildcv . 


;'  i 


i'iS  ■■ 

f     1 


1  i 


LAl{VNti(»S(()l>V 


Ki 


will  natiinilly  lie  in  a  ri'versfd  position;  that  i.-.  lln'  loimur  will  lie  in 
a  posterior  ])ortion  of  the  miii'oi-.  and  the  posterior  wall  of  the  pharynx 
in  the  anterior.  The  ri^ht  and  left  >idi>  will  aUo  be  reversed.  i'>e- 
^rinniny,  then,  at.  the  upper  mai'^in  (d'  the  iniaizc.  the  fir.-t  thin,L'  .-^een 
is  tlie  liase  of  the  ton^ne.  ami  in  t'roiil  of  it  the  nnich  which  separale.- 
it  from  the  epiulotti.-.  'I'his  oi'L^an  eonie>  ne\l,  ai'ehed  in  nio>l  ea<es 
like  a  how,  with  the  eoiieaviiv  in  front.  (>ii  either  side  (d'  it  are  the 
j)har_vni;'o-epi^lollie  ''ohls.  'I  he  color  of  the  epiglottis  i~  yellowisli 
pink.  I'siially  blood-vessels  may  I-  ecu  seail  'ittl  ovei-  it.  iieiu'alh 
tlio  eonoavo  snrl'aee  of  the  oriian,  it  ihe  vocal  cord.-  are  open,  will  be 
seen  a  trianu'iilai'  openini;  wi'h  ils  apex  under  the  epi^lotti-  and  ils 
base  toward  the  front,  of  ])ink  lolor.  wilh  wliili,~h  ci'o-— liai's.  This  is 
tilt!  internal  >uilace  id'  the  trachea,  alivady  nu'nlioned,  |)ircctly  t  i 
tlie  I'i.ulit  and  h'ft,  fm'ndu.L'-  the  aims  of  th<'  triani^le,  are  the  luoad, 
white  vocal  bands  fornnni^'  the  i^loitis.  When  the  \ocal  coi'd-  are 
(dosed  the  trachea  will  not  lie  seen,  but  tlie  two  white  coids  w  ill  ^iretcii 
fi'oin  fi'oiit  to  back  parallel  with  caidi  ■ithei-.  Ivxtcrnal  to  the  li'Ui!  eord> 
are  two  trian.ii'ular  surfaces  (d' a  muidi  darkci'  hue,  their  ba,-e-  beneath 
the  epiglottis  and  thei'-  apiiH'S  stretehinu"  to  the  fi'onl  almost  the  full 
len,irth  of  the  vocal  cords.  'I'hesc  are  the  vcnii'icular  liaud-  Tluy  oc- 
cupy a  bi,t;her  plane  than  the  vocal  coi'd,-,  lieinu'  dii'cctly  above  and  ex- 
tei'iial  to  tlu'in.  Hetween  the  two  on  eaidi  .-ide  lie-  the  \eniricli'  of 
Mori^a^iii.  Still  i'arther  to  the  riuht  and  left,  ami  1ia\inu-  their  oriLrin 
at  llu'  linut.s  of  tlie  epiirlotlis.  we  have  the  ri.ulit  and  Icfi  aryepii^h  ttic 
folds,  eonneetin.tf  the  eiii.iidott  is  with  tlie  ai'ytenoid  carl  ilaucs.  As  they 
approaidi  the  latter  they  eonvcr,L:e  and  near  tln'ir  cxti'emilic-  are  en- 
larged by  two  little,  round,  projectinu'  biilu'c-.  The  lir-t  i-  the  carti- 
lage id'  Wrisberg,  the  second  the  capiliiliiiii  Sanlormi.  .\cro-s  the 
anterior  side  of  tlir-  laryngeal  mirror,  conneciing  the  two  aryepiglottic 
folds,  is  the  intorarytenoid  ccuumissui'c,  thus  completing  the  circle  of 
the  internal  larynx.  Outside  the  aryepigloti  ic  bild-  are  two  pyramidal 
cavities,  called  the  pyriform  sinuses,  while  si  ill  furl  her  in  the  front 
part  of  llie  image  is  the  compressed  opening  to  the  le-ophagus,  lying 
slightly  to  tlie  r'ght  side  of  the  pictuie,  meaidng  iiidi\  idiially  to  the 
left.  Tills  is  liidden  nujstly  by  th(>  extensive  folds  of  the  po.-t-pharyn- 
gea!  wall. 

Returning  to  the  interior  of  the  larynx,  in  certain  positions,  ami 
in  some  larynges  nun  h  nuu'c  clearly  than  in  others,  directly  Ixdow  the 
epiglottis  and  above  the  aiiLrle  of  the  vocal  cords,  we  find  the  cushion 
of  tlie  ej)iglottis. 


:iii 


m^i: Asi:-  (i|-    i  in;   i.Ain  w. 


'I'lic  iiiiiciui-  nifiiilM'iliii'  i\\'  the  liiryiix,  as  dhscrvcil  liv  aid  nf  llic 
laryni:(i-(ii|ii'.  i>  df  a  li'jlit-|iiiik  cdlnr.  'I'licrc  slmuld  he  \\n  acciiniiila- 
iioM  (if  niiiiii>  aiiyw  lii'if.  ami  in  \  ncalizal  inn  thr  xnciil  curd-;  .-hduld 
cdiiK'  freely  tii^cl  liei'.  willidiit  any  iiilerrerenee  fi'nni  a  tliiekeiieij 
niiied-a  iict  uccii  I  he  aryiciinids. 

W  illi  I'l'L^ard  In  the  |Hi>itinii  nf  ihc  |iali('iil  fni'  lai'ynuiijooiraj  e\- 
ainiiiatidn.  it  i>  udl  fm'  the  n|icrat(ii'  In  accii>tiini  hini-clf  In  \\\v  w-v  liy 
I  he  pal  ii'Ut  n|'  any  >lnn|  nr  cliail'  W  llii  ll  at  t  lie  time  happens  to  he  enll- 
Nellielit.       Slill.    in    hi-   nun   <illiee    it     i-    lietlel'   In   lia\f   an    npiTat  i  llLI'-elia  i  f 

specially  -nited    fdr  \\\r  irealinent   nf  the  majnrii\   df  In-  eases. 

In  lafynu'dldiiieal  Wdi'k  the  patient  >hdidd  sit  eitluT  pei'feetlx  n|i- 
fiiilit  "V  leaniiiLi'  fdi'waid  in  ni'def  td  hriim'  his  head  w-.w  \n  that  df 
the  dpeialdf,  and   in  the  line  (d'  jieidVet   virion. 

In  dfdei'  Id  aeenmplish  this.  I  had  my  nperat  iim-ehaii'  made  with 
a  -trai^^iit  hack  and  li'anin.ti' .-li^ht  ly  fdi'\var<l.  The  hack  ilself  feaelies 
ahdve  the  liead  df  the  tallest  patient,  and  has  down  it>  eenii-e  a  deep 
and  wide  ui'd(}ve.  td  lit  tin-  haek  df  the  head  df  aii\  patient,  ydiiiii;'  df 
did.  'I'liis  pi'e\ents  any  hackwai'd  jerkiiii:'  when  the  head  is  rested 
airaiiist  it.  'I'he  cdmaxe  -nchn  <■  likewise  militato  ai^ainst  any  side- 
ward iiiiivemeiii.  while  it  eiialde-  tile  patient  td  slide  the  liead  ripward 
iir  downward,  and  to  adjust  a  \  iew  (d'  the  parts  to  tlu'  re([niri'inents  ol" 
tile  operator. 


(  ii,\i'ii:i;  I. Mil. 


AiTosi  Mr^ 


V: 


l\    l>!i-">.    AHrcil    Kii^lciii.  Ill    i'li-rlin,   in' I'lMJitcn!   to  \\\r  jiiciliciii 

il'nri--!(il)    ;l    lieu     llirtll(i(l    <>(   (A;!  Ill  i  II I IIU    t  llr    lilTVlIX    iiml    triH-ll.';!    wllifll 

II'  -lylcil  ■■iniln-.(()|i\  .'■  r>y  llii-  he  iiUMiil  ilirrct  limar  i]i>|pi'i-linii 
lirmiijli  the  inniiili  i<i  ijic  Inwcr  plMi'viix.  I;irvn\.  iiiid  tnu-hi'ii  \\illiiiui 
lie  iiiil  nf  a  iaiyiiLiial  imiinr.  in  llic  rullnwiuu  year.  Max  'I'linmiT. 
>l' ( 'iiiciiinati,  ya\r  an  rxccljcnl  t  ran>lal  imi  inin  liic  l';n::li-Ii  laii;^uat:e 


l-"ii;.  liiT.  r<i-iiniii  \u\-  :i iiin-,  ,,|i\ .  I'lij^  |ili(aiijr|:i|,||  wic^  takt'ti  from 
:l  |i:ii  1 1\  >l  ri|i|  (  il  |i;(tir]it  in  ni'lir  to  -liiw  di^liiiitly  tlic  jin-ition  <:!'  head 
anil    lick   diiriiiL.'  csaiiiiiiiit  iuii.      'Al'hr    Kii  >li  in  'I'liniiK  i .  i 


1)1'    Kirstc'iu's   iiioiKiirraiili,   with   adilcl    iiiiprnviriH'iit-^  a-   llic   iiu'tlio'l 

Ix'cauR'  inoro  coniiilctc. 

'i'lio  necessary  i(iii(liti(iii>  lA'  a  (•(iiii|)|c|i'  linear  iii>|ir(tiiiii  are: — 
1.   "'I'lie  liddy  iimst  lie  |ilace(l  in  >;iili  a  |in,-'tinn  tlial  an  iinaL'inary 

eoiitiniiat  inn  n\'  iln'  larynirn-t  ladical  liilie  wdiild  fall  williin  the  npcn- 

iriL''  of  the  inmilh  (Kiir.  ]()?). 

•^'.  "'I'liis  iniajiiiiary  straisflit  line  must  ho  eleared  of  those  partf 

of  (lie  liod     (epiirloltis  and  tlic;  base  of  the  tongue)  wiiich  o])struct  it." 

(;n:.) 


oKJ 


i)isi;.\>i:s  oj'    Tin:  i.akvnx. 


'\'\]r  (ir.it  c'undilinii,  il  i~  said,  will  lie  ohlaijicd  liy  ,i,M'iilly  tilting 
tlic  head  backward  so  that  tlic  axis  of  vision,  instead  of  being  at  an 
a  null'  of  ninety  degrees  to  lln'  axis  of  the  ti'iink,  will  he  at  an  angle  of 
about  inw  hundred  and  thirty-live  degrees. 

'i'lie  iseeond  condition  can  only  l>e  oijtaincd  by  drawing  the  base 
(if  the  tongue  forward  and  downward.  'I'o  secure  ibis  position  a  spe- 
cial tongue-depressor  is  i'e(jnired,  wiiicli  must  be  slipped  directly  over 
the  cii'eunnallale  papilla'  [a  the  ront  df  the  tongue.  Pressure  foi'ward 
now  upon  that  organ  will  remove  it  out  of  the  way  of  vi.-ion,  and  at 
the  >auie  time,  by  compic-.-iug  the  median  giosso-epiglotlic  ligament, 
ele\ale  ibe  epigliill  i.-  and  -o  di.-pose  of  the  I'emainiiig  olisl  ruetioii  to  the 
view.  Jn  some  cases  it  may  be  neecs.-ai'y  to  slip  the  in>ti'umeiil  nxrv 
the  epiglottis  itself,  and  draw  it  forward,  bebue  the  reipiii'cd  view  can 
be  obtained;    in  these  the  use  of  cocaine  will  be  rei|uiied. 


Fiiif.    jus.     Auliisiopc    V.  itli   jilatf    (/')    iiisti'iitl   ot    IhhuI. 
( A f, ir  K irslt'i n-'rii( iiiuT. ) 


Owing  to  the  position  which  ',  e  examiner  has  (o  assume  in  prac- 
ticing autosco]>y,  .the  ordinary  stationary  light  required  for  laryn- 
goscopy is  useless,  and  lie  must  cither  have  an  electric  lamp  fastened 
to  liis  own  forehead  or,  what  Kirstein  considers  better,  a  species  of 
electroscopo  attached  to  his  special  tongue-de])ressor.  This  transmits 
the  light  along  the  groove  of  the  spatula,  into  ihe  larynx  <d'  the  ]ia- 
tient.  wiihout  its  origin  being  seen  by  the  operator  (Fig.  108). 

The  autoscope  c(msisls  of  three  ]iarts:  a  spadila.  a  hood,  and  a 
handle. 

The  spatula  for  aibdls  is  1  I  centimetres  huig;  I'  centimeiies  wide 
at  the  tip.  which  is  thickened  and  i-ouiub'd  lo  avoid  injury  to  mucous 
membranes,  and  notched  to  receive  the  nu'dian  glosso-epigloUidean 
ligament;  ami  1  '/.  centimetres  wide  where  it  jiasses  over  the  convex- 
ity of  the  tongue;    this  portion  should  be  grooved  longitudinally,  lo 


Al  T()S((>I'\ 


34T 


!  i 


fit  into  tlic  iiiitunil  groove  which  the  tmiiiui'  (wliiliit.-  on  (■(.■iitral  do- 
jMc^sidii.  'i'he  ti])  (if  the  spaliihi  is  Ix'iit  (low  iiwaril.  1  coniiinelro  lower 
than  the  onliiiarv  uroovcd  portion;  so  that  it  lan  |iif.--s  upon  the  base 
of  ijic  toiiLiuc.  ami  liv  this  iiican~  laisc  the  cpi^jlott  i<.  'Hn'  in-t  riMuent, 
is  made  of  itiekel-plali\ 

The  lu)od,  whieli  is  uiaile  ol'  the  >ainr  niatri-ial,  i~.  for  the  adull, 
li  i-cntiiiieli'ts  Ioiil;'  and  :)  ceJitinietres  wide  It  Ills  iipnii  \\\r  I'ront  end 
<>(  the  -paiida,  and  si  rvi'-  to  keep  the  pa.->a'^i'  cltai'  for  li,L;ht  and  vision. 
.It  is  inserted  witliin  iln'  mouth,  and  i>  adjii-la^M.  .  prevent  iiii;'  oh-true- 


Fig.  toil.-  Au1i)S((j]iic  iijicrutiiin.     i.\ttcr  Kii>tciii 'riimru'r.) 


tion    from  the  np])er  teeth,  npjiev  lip.  or  mnstaelie.     'j'hc   medium 
lieiirht  of  Kii'stein's  standard  hood  is  almnt  '!  millimetres,  the  slit  beins: 


imply  wide  for  examination  purposes, 
le  used  the  hood  slioni 


W 


■n  instruments  require  to 


III'  of  greater  liciLiht.  I'hc  handle  i.s  ,<cl  at 
riirht  an,!J:les  to  the  sjiatula,  and  to  it  is  attached  h\'  .-peeial  contrivance, 
the  electroscope. 

Kirstein  says:  ''Autoscopy  is  a  (U/Jlcnll  act,  until  one  has  aecpdrcd 
a  certain  hard-to-defino  knack  in  introducing  the  simtula."  The  pa- 
tient shoidd  bend  the  upper  jiart  of  his  body  slightly  forward,  as  in 

23 


:ms 


DISKASKS    Ol'     rilh;     I.AltVNN. 


l''i^s.  111')  iiiid  |ii!t,  niakiiiL;  tlir  iiii-|i;is-;iL;('  in  ;i  -oiiH'wIial  diicci  line. 
'I'liis  .i,M\('>  llii'  iidilil  iniiiil  iiil\iiiihiL;c  nf  rclavini;'  tlir  iiiii>cl('<  (t{  tlic 
neck. 

W'liilc  iuit(i.-((i|i\  li.is  ihc  isvt'ixi  advantiiL;!'  (if  dinct  vi-inii,  it  is 
accoiiipaiiii'd  liy  scNcial  iiicnmciiii'Mccs.  'I'lic  cliicd'  nin's  arc:  1.  'I'lif 
(■.\|icns('  (pf  till'  i-('(|iiii'i'd  ai'iiiaiiiciitai'iiiiii,  I'nr  (i|)riMt  i\c  iiist  iiiim'iii> 
woidd  ic(|iiii'c  In  lie  .'-iii'cialh'  siiiird  I'm-  aiilnscopic  uoik.  'J.  'I'lir 
IfDiililc  (d'  ac(iiiiriii;i;  the  l('cliiii<|ii('.  .'!.  'I'lic  cIum'  proximity  of  the  -iir- 
ircnii   III  llir  direr!    Iircalh   nf  llir   |ialiriil,   willi   all   lliat  tlii>   iiivnlvcs. 

Still,  in  llir  wiird^  nl'  Kirslnii:  •■i''ni'  llir  piirpuscs  of  sririililic 
dciiiniisl  rat  inn  anlnsmpy  i'   jiisl  llir  lliiii.u;   a  riiiiiiiirr  ■<(  spnialnr.-,  can 

ln(d\.    ntlc    al'irr    ailnlllcr,    llimilLlll     iIh'    ailln-mpr    and     llnic    llir    ciindi- 


II 


i-'ii:.  i  1*1.  I  onj^uc  (|(  )in  ^^111  llir  phai  vii;;oMii|iy  and  ijiicct  iai\ii;;ii 
t  raclini^i  ii|i\ .  Side  \  icw  and  surl'air  view  of  I  hi'  aiilcrior  portion.  In  ^oiiic 
{■MM's  an  insli  iiniriit  with  a  laiiriT  curve  of  the  anterior  |)orl  ion  i.,  more 
prael  iealile.      (.M'ler    Kii -tein  'I'liornev.) 

linns.  In  pcrsniis  wi'll  adaplcd  In  anlnsrnpy  it  i>  i'a>v  In  di'iiiniistrad* 
In  any  layman  tlir  ninvriiu'iils  nf  t  lie  vnrai  riud,  llir  |iliy.-^inlni,Mcal  |)iilsa- 
linn  (if  the  wall  nf  llir  iraclira.  llic  >yslnlic  liralinu'  <'(  llic  hifnrraliun- 
spnr,  and  i|iiit('  a>  easily  a  eareinoma  nf  llie  larynx." 

In  many  eases  llie  llimat  is  <<)  furnied  that  even  llie  .-killed  e\- 
iiminer  can  derive  nn  ad\antaL!'e  fmm  the  use  nf  liic  aidn^enpe;  htit 
the  Iriiiinpli  o\'  antnsenpy  lie-  in  llie  iiienmparalile  view  witieli  it  uives, 
in  many  nllicrs.  nf  tlie  pnsterinr  wall  nf  the  larynx  and  lite  i mire  inner 
siirfaee  nf  llie  Iraellea  e\en   In  the  etltra.ae  nf  the   litniirhi. 

A«  aiiinseiipy  ran  he  praelieed  willi  faeilily  uhile  the  patient  is 
under  llie  inlliieiiie  nf  all  ana"-tliet  ie.  il  is  prnlialile  that  it  wiM  lie  re- 
ceived willi  miicli  fiivnr  for  the  examinatinti  nf  yninii,'  ehildreti.  with 
whom  Iai'\  nonsenpy  is  itsiiiilly  '^neh  a  diniciill   matter. 


I    i 


A  i;  TOSCO  I 'V. 

'k'  iii>lriiiiifnts   for  iiiihiscdni, 


.•illi 


iIMT;iti..ii>  aic  .-Ii,i|„m1   Ilk,,  nii.sil 

n.s.unn.nls,u„l,  l,„„,,-sl,,.,ns.     TImv  >l M  .....asur.  .ImhU  .'..  .•,.., (,- 


,  ,       ,  ,  ,  -      I'liil,  auioxdiiic 

"''•■''""'"■^^'""''•'    l'"":iS.,.Mh,.M,    l:MV,mnM.„p,r   on,..    (|.',.      ,„.,, 

Sin...   inlro,!,,,.,,,^  ihis   nrw   n,ril„H|   „r  ,.x;,nnM,,m'~t  |„.   larv,,..,.;,! 
'■"vily.    Kirsl.M..,   loronlinarv   pur,,,.,..,   l..    ...n.uhat    sMMpl,li,.,rins 

''■•■'''"'I'"'-      ^'''"^-  ''"-^  '"-'"•  ".   ^vh.-i,   (|„.  I I   ,.  „„,,.,.....,rv    ami 

'"^vh„.|,,|,,.„.oov..,.anl,k..u,s,.  I„.,|,.p,.„.,.,i,,„|,      |  f  ,„ ,.,  |,„„:.  ,  |„. 

^''';' '''   ''"^""    '""-'■'•'•Nn..,   uhil,.   Ii„.   ^,„!,|.    ivMun,.   ,|,r  .„„..  ■,. 

;"     'V"'",'""'  ''"l""^-"'  "'V.    110).      In.„.a.l   oni,,.  „|.,„,,.,„,„,.„„^ 

'''■''7/  '•'  '^' '^l'''''''^'-  'I-  l--l-'''l-l'uli-  nf  Ih..  ,,,,,.,.al,,,Mv,,Ml,l  auMw.r 
('(jiiiillv  \\,||. 

^;;'\;'-"'''l-"i"|'niMwalap,,li,.aliononi,,.  ,n,l of  op„,,_ 

'""•^'^'^  """•'"■'•''^'^•■•■|""-"-''M.a:-..  ,n  wl,„.|,  i„.  n.,Mo.,.,lap„.'.,.,;r 
'•'""■  '-"■  '■'•'Mi.M..nv.  lon,^,  from  th..  supra,loMi,.  p„,,ion  of  tl,.. 
,'•;""'  ='.V"""^n,ana^..,|-il.     T p,.,.al,on   ua.  ,ion.  hv  thr  ai.l 

"',"'"■•'."""'"'"'  ^^i'l"""   "'•■us..  or..o,.an,.Ml„.  ,in„.  n.,pnn.,|   !„  in.r 
only  a    lew  s..<-,,n,|>,  '  '^ 


!!«!   i 


'    \ 


I     ! 


IF^ 


ClIAI'TKi;    1-.\1\ 


INTUr.ATIOX. 


Tins  iii('tliii(!  (if  rclicviiiL:'  huTiiircal  sU'iiii>i.-  lins  lnll^r  been  ii 
Uicorv,  cniilc  iii.-truiiiciits  Ikmiil:  iisnl  to  ol)tiiiii  the  object  in  view. 
Tliev  were  not  ol'  iinicli  Viiliie,  however,  and  it  remained  fur  O'Dwyer 
to  introduce  to  llie  ])rofession  (lie  nielliod  itself,  with  a  I'lill  set  of  in- 
slnunents  eaiiahle  ot  aceojnpli.sliing  intul)ation.     Ui.s  own  record   in 


Fin-.    11 1.— ()'I)«  vcr's   iiitiiliiitidti  set. 


the  nse  of  tliese  insi runieiits  lias  been  brilliant  indeed,  the  regret- 
table feature  lieint:  tliat,  at  the  moment  when  O'Dwyer's  tubes  had 
obtained  a  world-wide  reputation,  and  the  advantages  wliich  his  re- 
searches had  given  to  seit'iue  were  being  fully  realized,  lie  should  be 
calle(l  j'nun  his  labors  and  the  glory  whieh  was  the  product  of  hi- 
genius.  The  .saddest  feature  of  all  is  that,  notwithstanding  this  crown- 
ing effort  for  the  good  of  Itumanity,  he  died  a  poor  man. 
(350) 


IMl  HAl  ION. 


351 


()"J)\vyL'i'>  lubes  consist  of  ;i  .>-iri(s  nf  in.-tnimcuts  nl'  ditlVrciil 
lengths  iuul  sizes,  to  .-iiit  the  vniinus  ;\-j:v>  nf  piitieiits.  liesides  tlie>e, 
tliere  is  an  introducer  iind  an  extractm'  thai  will  lit  all  the  tiii)Os.  Add 
1(1  the>e  a  iiioni li-iiaL;  and  a  .-eale  tu  rriiidatr  the  siz(>  (d'  ihe  tulie  in 
aeeerdaiiee  w  ith  1  Ih'  ai^e  of  the  pat  ielit.  and  the  mitfit  is  eomiilete  ( l''igs. 
Ill  and  \A->). 

Tile  liilie  is  a  llallened  eylinder  Ind.Liiim  lnwanl  ihe  emlre,  'I'lie 
head  is  roiindeil  and  llan^rinj:.  id  re>t  mi  the  ventrioidar  l)and>.  and 
thiMiiiih  eiie  >ide  nf  tlir  head  is  a  [K'rfnratinn  fnr  iln'  in-ertinii  nf  a 
cord. 


■i<:.    112.     IiwtriiiiKiit-   for   iiituli;i1  imi :     iin    iiii  rudiiri'i-;     il)\    tul 
((•;    .scale;     !'/)    c.xtiiictiir:     C'l    iiiniith  j^ii^-. 


;ret- 

had 

ro- 

l)e 

hi^ 

Wll- 


Tlie  iiitrndiiccr  (•(insi>ts  nf  a  -Ifuder  md  lilted  \\  ith  a  liandle.  On 
it  is  a  slidinu-  tniie.  .\t  the  dista!  end  nf  the  iiitrn(lii(ir  i>  tlie  nliluratof, 
a  thin,  jninted  jiiece  nf  indal  which  i-  -crcwcd  nii  tn  the  iiil  rodiir-er 
at  riplit  anL;h's.     'I'his  passes  iliruiiLili   the  juhe. 

'\']\o  t'xti'actnr  i-  fnr  the  )nir|io-;e  of  reninviiiLi'  tin'  luhe  when  de- 
sired.    It  is  shaped  with  a  rii^lit  an^de  soniewliat  like  the  iidrndiicei'. 

'I'hi^  ninuth-ii'ai:-  i-  tn  keeji  ilie  jaw-  apait  diiriuL:'  the  nperatinn. 

To  ]ierfonn  intnhatinn  diiriiiu'  infancy  nr  cliildhood.  the  jnitiont 
-hnidd  lie  wrapped  in  a  slieej  fmni  the  neck  downward,  so  as  to  se- 
ciiroly  liold  the  arms  and  hands.  Tfe  slmuld  then  he  hehl  fmni  In'hind 
in  tlie  upri'jlit  imsiiion  either  in  tlie  lap  of  a  niir-e  or  -fandinir  on  a 


I)Isi;asi>  or  tiik  i.akynx. 


(  liiiir,  'i'lic  iissistiii-  siir:;c(iii  slumld  lioM  the  jSiXji,  placed  in  iK  Id't 
side  of  I  lie  iiiniitli  of  the  iialiciit.  taking  care  to  jifcss  the  liandlcs  ligiitly 
iiu^aiiist  tln'  chi'clv.  to  )ii-('\i'iit  the  .-lippiii';  ol'  the  instrument. 

TIic  ojiciiitor  >tiniils  iniineiliately  in  front.  'I'lie  introdiu'er  is 
held  in  ilic  rijilit  iuind.  The  h  ft  foicljnjrfr,  disinfeeli'd  ami  oileil,  is 
ihii)  )ja.->eil  into  till'  |ihai\n\.  tin'  e]ii^dotlis  i'onnd,  and,  .•^lippin,^'  the 
(inLicr  ovei-  it,  the  ea\itv  iietweeii  it  and  liir  aivtilioids  is  di'teeted. 
Imniidiatelv  the  end  n{'  the  tnlir  attached  to  the  introdui  ri',  and  aimed 
with  a  sti'oii;^'  thread,  i>  pa.s.'^cd  along  the  palmar  surface  of  the  linger 
already  toiiehing  the  larvnx.  and.  guidi'd  I'V  it.  is  slipped  over  the 
I'piglolti^.  The  handle  of  the  introducer  i»  now  raisi'd  so  as  to  direct 
the  tiji  (d'  the  in-t  iiiineiit  direellv  into  the  laivnx.  If  this  is  not  done, 
the  tiilie  slips  o\cr  the  lonimissiire  into  the  (esophagus. 

The  tiihe  having  eiitcfed  the  larvnx.  of  which  the  operator  may 
lie  sure  hy  feeling  the  soft  tissue  all  around  the  liihe,  the  thunih  is 
pressed  on  the  hiitton  of  the  slide  and  the  tidie  sep;iraied.  in  remov- 
ing the  intiodiieer  the  left  foiellnger  slionld  be  kept  on  toj)  of  the  tniie 
to  secure  it>  releiiljoii. 

.\  lingei-giiard  is  recommended  by  some  operators.  Tt  is  a  cnm- 
liersome  eont  ri\ani-c,  and  in  yonng  children  there  is  little  enough  space 
for  the  linger  alone.  1  have  never  nsed  oiu-.  and,  although  1  have  had 
the  linger  hit  ten  once  or  twice,  in  each  case  it  has  been  caused  hy  de- 
feet  ivi'  holding  id'  the  mouth-gag:  something  which  could  always  he 
avoided. 

If  failure  of  insertion  occur  on  the  first  attempt,  the  cliild  should 
\n'  allowed  to  rot  a  few  minutes  before  a  .second  attempl  is  niadi". 

When  the  tiiiie  heconu'^-  t)loekecl  by  false  membrane,  dnring  or 
immediately  after  its  introduction,  so  as  to  jirodnce  threatened  sulfoca- 
lioii,  it  should  at  once  he  removcfl:  and  after  a  little  while  anotlier 
trial  made,  in  ease  o\'  failure  id'  elfecting  ininl)ation,  tiacluoi  nnv  may 
in  some  cases  be  required  in  the  attemjit  to  save  life. 

In  adults,  and  youths  |)o.sscssed  of  sntlieieiit  self-control,  intuba- 
tion may  n  ailily  be  accomplished  without  the  u>e  of  the  left  forefinger, 
iuit   l)y  means  of  (he  laryngeal  mirror. 

'1  he  thread  should  not  lie  removed  until  we  are  snre  that  the  tube 
is  not  only  in  position.  Iiut  also  that  there  is  no  danger  of  its  being 
occlmbd  liy  memlnanr.     Then  it  ean  be  slipped  out,  care  being  taken 

not    to   remo\e   the   Ildie   while  (biillg  so. 

To  reiiuue  the  tiilie.  the  patient  is  airain  placed  in  the  attitude 
rei|iiired  for  it-  ini riHluetimi.    The  extractoj-  i-  earried  down  along  the 


IN  I  I  HA  I  ION. 


left  index  fin;:cr  a>  in  the  itriinnrv  (tpcriitinii.  'I'lic  inoiitli  <il'  the  tiilx' 
is  A'll  liolow  tlio  t'pij;l()ttih  imd  llic  clu.-nl  tips  of  the  cNtnu'tor  inscrtril 
into  the  ojx'li  tlllic.     \\\  pressing:-  the  spriiii;'  tiic  lihidcs  jiii'  njicncd,  iilid. 

,Lrrii>]iiii,L:  tlif  iii.-idc  \\all>  <il'  tln'  tuiic  iIliIiiIv,  tlic  liittcr  i-  ;ii  (HH'c  willi- 
dr;c,\ii.  'I'lu'  ri'iii(i\al  i>  (dlfti  a  iimrf  ditliciili  npcialhiii  than  the  inli'n- 
diictidii:  and  to  render  tlii>  part  dl'  the  wdi'k  la-ier.  .Ma\  '!  Iinriier.  n\' 
Cincinnaii.  lirou,i:lit  hei'ore  Uie  pinle^imi.  u  the  |a-t  ineetiiii:  ol'  ihe 
Aincrican  Larviii:o|oi;ieal.  TiliiiiolniiicaL  and  Oldleoujil  Sdeiety,  a  de- 
sitrn  helicM'd  ti>  he  an  iinprn\  einent  upmi  (»'ii«ver">  extractor  and 
tnhe.  'I'hi'  rorinalmn  of  the  tnlie  i-  the  >anie.  with  llie  exception  thai 
the  liead  i>  more  wiihiy  and  ninic  (h'cply  ccmcave:  ,-o  lh:U  when  the 
extractDr  touches  tiie  cavity  it  will  ulide  inoie  ri'iidily  into  it.  'I'ln'  ex- 
tractor itseir  is  likewix'  >iin]ilcr  in  I'orin,  and  serves  the  donhie  purpose 
of  int  I'ndncer  a.-  well  as  cxt  lactnr. 

Sunietinics  the  lidie  i-  cdii'jiied  mit  and   will  re(piiic  I'ein.-cii  inn. 

One  (if  the  main  dillicidtio  in  cniinectinn  witli  inlubaiion  i>  the 
dilliculty  in  de,L;lntil  ion  which  allend>  it.  particnlarly  in  rcd'ei'ence  to 
llnids.  S(d'l  foods  can  n.-nally  he  swalhiwed  if  t:iven  slowly  and  with 
care:  hnt  tlni(].-~  ai'c  likely  to  i^ct  thi'on^h  the  tnhe  intn  the  larynx  and 
trachea.  Wy  ailoptinu'  Cary".-  inelliod  (d'  placinu'  the  ]>aticnt  (ui  his 
hack  with  the  hip>  well  elevaled  swallowini:'  is  said  to  lie  ea>ier;  and 
in  some  cases  small  (piantitn-.-.  e\in.  of  linid  can  lie  iriven  in  tlii>  way. 
In  any  ca.'^c  llind  nonrishnii'iit  can  alwavs  he  adnunisteicd  liy  eneniata. 
the  chief  part  of  it  heini:  readily  alwui'lieil. 

Intnhatidii  i-  lare'cly  n>ed  in  case,-  (if  lai'ynu'eal  diphtheria  dccnr- 
rinii'  ir  cliihlreii ;  and  -ince  the  int  I'ddiicl  ion  df  antitoxin  inlc  i  he  t  reat- 
nicnt  of  this  di>ease.  the  fatal  i-.-nes.  when  the  two  arc  cdndiineij,  have 
ureatly  dimiiiisln'<l  in  ninnhcr-.  while  tlu'rc  i-  nn  dnnii!  w  haie\ci'.  even 
wlieii  nse(l  aldiie.  thai  it  ha>  saved  many  live.-.  The  fad  df  iidnhalioii 
heiiie'  accdinplishcd  v\ithdwl  the  n.-e  of  the  knife  ha-  can-cd  if  to  he 
received  with  mncli  favoi'  hy  parents  and  fi'icnd-  of  nalienl-  I'eipni'ini;' 
o|)eration;  and  foi'  this  i-caxm  it  i-  fre.pieniiv  preferred  id  ihe  seeni- 
iiiffly  iiidi'c  <eri(ius  dpci'atidn  (if  trachcdldmy.  ( 'a>M'|licM'y  relates  tlie 
history  of  foni'  cases  also,  dccni'rinu  in  adidt-.  in  which  inlnhation  re- 
sulted in  tie    t  lii'    of  this  di-ease. 

( >"1  >wy(  r  ha-^  lonnd  intnhatidn  -crvicealilc  in  a  niimhei' df  cases  df 
slrictnrc  froin  PiliaiT  sypliilis  in  the  adidt.  Other  ohsei'vcr^,  ton,  fol- 
lowinir  liis  example.  Inive  attained  a  measnic  df  .-ucce>>  in  the  same 
way.  De^rlntitidii  in  these  cases  i>  said  in  he  cumparativ cly  ea>y.  after 
the  fir-t  dav  di'  i  v\ d. 


I  I 


IMAGE  EVALUATION 
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Hiotographic 

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clIAI'IKIf   lAV. 


TUAriii;(»T(»MV.  Tiivi;(»i().\n 


'Tit \(  iii:<)To\iv. 

I  I'  li>  llif  liiiu'  dl'  n'huvcr".-  (Ii.»(()\('iy  nl  iiit ulml inn  lliis  was  (lie 
'•Illy  oj)enitioii  knnwii  fur  ilic  relict'  of  sull'dcntioii  arifsiiitf  from  luryn- 
;:ciil  stenosis.  Sinco  tln'n  intiilnition  lins  in  iHiUiy  instancrs  taken  its 
place.  With  the  irencral  pnlilic  tliis  lias  also  liccn  received  with  more 
favor,  inasiniicli  as  it  is  a  Itloodless  operation.  Still,  there  are  many 
occasions  in  wliii  li  f laclieotomv  stands  ainne  in  it<  ntilitv  an<l  iii  which 


till 

I 


l'i]L:     ll'!       I'liilcd    1  liulicoloiiiv   liilic. 

intuhaliim  would  l)c  wmse  tlian  nseless,  while  there  iire  nthers  in  which 
the  choice  of  operation  inu>t  tiepend  npon  the  siir<ieon"s  judunn'nt  of 
the  eatie  |irescntcd  lo  liini  fnr  relief.  I'nrtlier  than  this,  numerous 
cases  Iiave  oecurrcd  in  which  intuhatiun,  ha\inir  lieen  ]>erformed  with 
unsnccessful  results.  trach(><itiiMiy  as  a  'hriiin-  nssart  has  heen  re(|uired. 

The  diseases  for  which  ihi'  (iperalmn  may  lie  retpiired  are  leih'ma 
nf  tlu'  larynv,  ahseess  of  tin  larynx;  syphilitic,  t  iihenuh  ms,  or  malij^- 
naiit  laryn.uitis;  the  presence  nf  nenpla-ni-  or  fiu'ciirn  Imdies.  paralysis, 
pseudomend)ran(nis  larynLMt  i-.  etc. 

Instruments  riMiniied  arc  si'alpel.  rctract«>i>,  tenaculum,  grooved 


riiAt  iii:»ir(»\i V.  ;>.».► 

dirccldi',  itniiiilt-furccps,  cf' ,  bcsidis  tlic  iiccrssiiry  iriiclu'uioiny-tulx: 
siiitalilf  Id  till'  n;;»^  ol"  the  pationt  (Vinf.  11.},  Ill,  11."),  W'ta).  Also, 
to  iiiiikr  tlio  oiitlit  complclc.  should  he  aiMcd  ncodles,  ligatures,  tapi's, 
:ciss(ii>.  iiiid  ar(('rv-(laiii]is. 

.\<  ii  I'lilc.  an  ana'stlictic  slnudd  ln'  u.-cd.  <ithfr  jronoral  or  local. 


I'i;.'.    111.      ll;oil  miIiIht  triicliciitdiiiy  liiln'. 

I 'mil  ncciill}  llu'  loriiicr  \\a>  always  adiiiiiiisterod,  cillur  I'tluT  or 
chlorol'onii.  In  cliildliood  this  is  an  iiiipoiMnt  inattcr.  as  il  is  dillicult 
to  hold  the  child  .>-till  inoULdi  to  pfrl'orni  ilif  operation  when  at  all 
sciisiMo  to  pain.      In  cases  where  liic  ilaiiLier  \i>  lilV  hy  dehiy  is  iiu- 


iich 
of 
•ons 
•ilh 
red. 
Ilia 


l-'i;:.   Iiri,     KNlicrg's  traclict  t<ini_\  tulif. 

ininciit  or  wlim.  ow  iii!.!  to  cailionii'  aspliyxiaiion.  tho  scnsiljility  to  pain 
is  materially  diininislied.  the  operation  may  he  donr  ai  onco,  without 
attcmjtlintr  aiiivsthosia.  Tn  children  of  larirer  trrowtli  and  in  adult-, 
hyiiodeniiic  injection  id'  a  -olntion  of  cncaine  in  the  reLMon  of  the  larynx 


•   !(.    ? 


:ir)(i 


IMSEASKS    OK   Till-:    I.AUVNX. 


or  iiji|i(>r  tniclica  will  answer  an  good  a  piirixiso  us  the  administration  of 
ii  ^M'licral  anirslli('tic. 

Ill  tiic  llr.rlincr  k'Uiiisrlic  W'ocltnisrkifl  of  Juno,  ISHS,  Friunkfl 
sptiiks  str()ii;ily  in  fuvor  of  lociil  iinastlicsia  in  tlicsi'  (a.-rs.  lie  lia^ 
|ifrfonii('d  trai'licoloiiiy  tweiity-tlircc  times  diirin^f  liie  last  liirei-  years, 
(he  patients  in  every  instance  litiiiL,'  iiiKJer  eoeaine  anu'slhcsia.  Many 
<i\'  tinse  operation.--  would  have  liccii  (hiii;;»'i(Hi<  under  a  i;eiieral  ana;>- 
tlietie.  lli.s  plan  is  to  inject  liypudcMiiieally  a  few  drops  of  a  *^'<l- 
per-cenl.  solution  in  two  ])lace.-  near  the  site  (d'  operation,  or  of  a 
lO-per-cent.  solution  in  four  places.  In  children  he  alway>  use>  the 
lO-pcr-ceiit.  solution.  In  adults  the  anioiiiit  injected  is  ahoiii  I 
cenli>rraninies  of  cocaine,  lie  >ays  that  the  patients  dreatl  llu'  cocaine 
less  than  the  ehlorofonn.  One  of  the  advantaires  (d'  ojieratioii  under 
lociil  ana'sthesia  is  the  reiiio\al  of  ;ill   nccc.^sitv  n\'  undue  ha<te,     \o 


l''!";.    lliV/.      IliOik's   1rii<'iit'ii|iiiii\  till)!'. 


1    ' 

niatter  how  ana'.-the.-iii  i-  |(rodueed,  it  i,>  ahvay^-  better  to  liave  o-ie  t>v 
more  assistants,  to  aid  in  the  \ariiuis  diilii'.-  n\'  the  operation. 

'i"raehe()toniy  may  he  I'iihcr  hiLiii  or  low.  In  ]iii:li  traelieolomy 
the  incision  into  the  trachea  is  aipo\e  the  isthmus  n\'  the  tliymid;  in 
low  it  is  helow  the  i,'>tliiiiiis. 

'The  former  is  the  one  usually  pei  l'(Uiued.  iiiasmuch  as  it  involves 
fewer  hlood-vc.ssels,  aod,  heiiiL:  nearer  the  external  surface,  it  is  easier 
of  accomjilishmenl. 

In  prt>paration  for  tlie  operation,  tlie  patient  is  placed  upon  the 
liai  l\  with  the  head  tilted  haekward  hy  means  of  a  roller  or  hard  pillow 
placed  heneath  the  neck,  the  ohject  heinjr  to  place  the  trachea  and 
larynx  in  a  jiromineiit  position.  'The  iieek  is  then  thoronirhly  and 
t|iii('kly  washed  with  a  -oliition  of  cuiro^ive  sid  liniale.  carlmlic  acid,  or 
other  disiiifertaiit. 


TIlArilKoiuMY. 


For  till'  lli^fll  (iptTiltioll   llir  ilUl^imi   li\    ihr  «(ill)Hl  >linlll(l   lie   llDIll 

lour  to  :«ix  continii'tn's  loii^f.  iiiid  diri'itly  in  the  mcilijin  liiif,  rMciid- 
ing  from  tlu'  oppnsilr  i  rici.tli\  roiil  niciiiluiiiic  ilircctly  dow  luvjiid.  Tlu' 
two  i'mU  of  tlic  incision  ^llould  lie  iirvdcd  ^iradujdly  in  I'mni  llu'  cx- 
icriiiil  surliicc  at  fitlnT  end.  milking'  tin'  loii^rcsl  part  of  tlic  cut  tlu- 
external  one.  Al'trr  tlic  lir>t  or  .-km  cul.  toiictlicr  with  tliat  td'  tlu' 
>upi'r(icial  fascia  lias  1.  \  uiatlc,  tlir  di-scctioii  inuiird  >lioMld  lie  carc- 
liilly  done  liy  iii('an>  of  the  scalpol-haiidlc,  nmic  than  the  Idadc. 

'I'lic  stcrntdiyoid  nui.-clcs  arc  now  Itronulit  into  view.  'I'lie  areolar 
tissue  is  pushed  a.-idc  hy  the  liandle  of  the  Malpcl,  and  tlie  nui.scles  arc 
held  apart  on  cither  side  hy  relraelor-;.  'I'lie-e  can  he  held  hy  an  as- 
sistant. 'I'iic  deep  I'a-eia  i-  iiow  ill  view,  with  the  thyroid  isthiinis  at 
llic  lower  end  (d'  the  cut.  The  part-  are  cleared  of  areolar  ti>siie.  e\- 
posin.if  the  two  lavcis  (d'  l'a>eia.  one  extendinu:  in  front  of  the  i-ihmns. 
the  other  hidiind  it.  The  istliiniis  ii.-elf  is  a  liltle  pink  liod\  nwv  the 
second  mid  thiid  riii;;.-  of  the  traehen. 

if  on  cxaniinalion  there  -eeiiis  tn  he  roniii  enough  tn  in.-eii  llii- 
mhc  ahove  the  i>|liliiii>.  the  deep  f,i.-eia  i-  iiiei-ed  fnim  the  eiicnid 
dowjiward  and  drawn  a-ide  hy  reirailo"-.  If  the  >pace  iippeai-  to  he 
too  ^iiiall.  a  traii>vei.-e  cut  is  made  throii;;li  the  deep  fascia  over  tlic 
<iicoid  cartila^i'.  It  jiiiist  he  hum' enoiit:!!  tn  admit  the  scalpeldiandle 
or  grooved  director,  which  is  al  once  iii-eriei|  and  >lid  down  hctweeii 
ihe  deep  fascia  and  the  trachea,  and  tilted  up  -n  as  to  e\|ii)sr  ihc  two 
upper  tracheal  rings.  In  cither  case  'lu'  ti-sue-  arc  drawn  a>ide  iiy 
ritractors,  the  trachea  >cized  hy  a  teiiaeiduiii.  and  the  lir.-l  twn  m  three 
lings  cut  in  the  mc(lial  line,  care  hemg  taken  not  to  iiici>e  the  po>ierior 
wall  of  the  traidiea.    The  linal  cut  into  the  trachea  should  tie.  hr  made 

until  the  lueniorrhagc  fr(Uii  the  luevioii-  iiici-ioii>  have  alialed  i>\-  I u 

cnntroUcd.  lvx|)ul>ive  cougliing  usually  fnllnw-  alier  the  tiaehca  ha- 
liccn  opened,  relieving  the  passage  of  any  sreietinn-  or  alsc  nieiiihiaiie 
iliat  may  ho  loose,  in  diphthcrilic  ca.-e-  the  suigion  .-hmild  prote<-l 
himself,  as  in  iiituliation,  from  iK  ■  contagion  <d'  particlo  of  mcmlirane 
expelled. 

As  soon  as  respiration  i-  frer  through  the  ailidiial  opcniiiLT.  as 
large  a  tlihc  as  will  freely  i  nler  >li(udd  1m'  inserted.  This  -hniild  lie 
wat(  lied  for  a  few  niiniile.-.  and  when  eoiiLihing  is  nver.  and  iircathing 

ihidugh  it  has  liee(une  natural,  the  tape-.  wlii(  h  had  I ii  previon-jv 

attaclu'd  to  the  rings,  should  he  fasteiii'd  round  the  neck  tn  hold  it  in 
position,  A  thin  piece  of  aiili.-eptic  ah.-orlieut  cotton  sluuild  lie  placed 
around  the  instiiimeiit  heiwccn  the  -hiejd  and  the  -kin  id'  the  patient. 


y. 


I'fi 


I.,.!j|t 


l"'1 


I 


.•{.•JeS 


iiim;.\>i;s  (»i    iiii;  i.akvns. 


'I'lic  low  (i|i(  rntinii  is  pel  rniiiicil  ill  ii  .-.iiiiiliir  iiiiiiiiitT  to  the  Iii^'h 
oiir.  The  c'littiiiL'  is  iiccis.-iirily  (Icciht,  and  ( oii>ci[u<'ntly  \\]v  incision 
should  1)0  l()n;,r,.|-^  cMfiidiiiL;  I'idiii  tlu'  ci'iroid  alinosl  to  (lie  stt'iiniiu. 
'I'lic  iiiiisclcs  to  he  held  n>id"  iiy  I't'traclors  aro  tlu-  stc'rnotli\  roid,  in- 
stead (d'  llif  stcriKdiyoid.  'I'licix'  is  niorc  (lany;(,'r  of  liii'Mionlia;:t',  as 
the  |)l('.\iis  of  vi'ins  over  tlic  trachea  is  larijcr  ami  more  c()))ioiisly  siiji- 
[ilicd  with  hlood.  ( Ircatcr  care  is  nectled  in  dissection;  and  soincliines 
the  tliyi'oid  artery,  extendinir  to  the  mesial  line  of  the  trachea,  scri- 
oic  ly  iiilcifcics  with  the  operation.  When  the  neck  of  th"  paticMit  is 
sliorl  and  thii-k.  the  operation  is  iiiiich  iiioi'c  ditViciilt.  'I'his,  however, 
is.  in  some  case-.  coiiiiterl)alaiiced  hy  the  fact  thai  llu'  lower  operation 
places  a  ^^realer  distance  lictwcen  the  wound  itself  and  the  laryn;real 
disease  tiian  is  jiossililc  in  the  hi.i,di  operation,  and.  other  thini^s  heiiii; 
e(|iiai.  would  L^ivc  the  paliiMt  a  ,i:reatcr  chance  for  life  (i'"i;i.  llii). 

With  rcfciciicc  to  Mftei'-treatinciil.  it  i<  essential,  in  either  cade, 
that  the  tiihe  ,-hould  he  (artd'iilly  watched.  .\ny  ohsf  ruction  that  miglit 
occur  in  it  shouhl  he  at  once  removed,  either  Ity  forceps  or  cotton- 
holder,  or  hy  takiiiL;  out  ihe  inside  tidie.  clean^ini:'.  and  retnrniiif^  it. 
riie  iiKUith  of  the  t  lacheoidiiiy-t  iilic  should  he  covi'ied  with  loose  moist 
antiseptic  naii/c.  'I'lns  should  he  chainzcd  repeatedly  and  re^idarly. 
'Tho  air  of  the  room  slioiijd  have  a  nniforni  icmperalure  ami  humidity, 
heinjx  constantly  charireil  with  tnoistnro  in  order  to  make  the  air  (d" 
respiration  as  nearly  the  saturation  point  as  possihle. 

The  length  <d'  time  the  tnho  is  worn  will  dill'cr  in  each  case,  ac- 
conlino'  to  I  he  circumstances  relatinj;  to  it  ami  the  nature  of  Ihe  dis- 
ease for  the  relief  id'  which  it  was  inserted.  'I'he  idiarijo  (d'  the  case 
^honld  always  he  placcci  in  the  hands  of  a  rompctent  nnrsc.  and  directly 
under  the  snr^'eon's  or  pliysiciaiTs  contnd. 


IIVUOKIMV 


Ii  I 


I'ii:  1 1 "  repres(  Ills  iIk  completed  opciation  for  ihyrotoiny.  (akim. 
loi^cllicr  with  l'"iir.  1  Hi.  hy  pi  rmi-sioii.  from  jio-worth's  recent  work. 
The  opciation  rcsinilijcs  somewhat  that  of  tiarheotomy.  Th(>  incisimi 
is  made  lhroUi.di  the  iiite,L:iiment  aloii:;  the  mesial  line,  exiendiiiL;' 
from  aiiove  the  thyroid  notch  to  the  ciicuid  rinir.  The  inti',i;umenr 
iieini:  retracted,  the  areolar  tissue  is  prcsseil  aside  liy  the  handle  of  the 
scalpel,  revealim;-  the  thyroid  carlilajic:  and  tlicn  with  a  stronu  sharp 
knife  an  incision  is  made  in  tlic  mesial  line  from  top  to  bottom,  'i'his 
incision  shmild  he  LM'aduall\  and  carefully  deepened  hy  suecessivr  cuts 


;lll)- 


4 


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ffc   ••    ;v> 


i 


<§P- 


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•I^r, 


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ill.  lii 


sr! 


iX: 


(1; 


,  i  tit. 


i 


it 

h , 


i! 


riiviioroM  V. 


;;»ll 


until  Ihf  iiiiudus  iiicniliiiiiR'  is  iciii'lirtl.  In  later  ailiilt  lilr  liu-  lliyroid 
(•artila^'e  is  frcijiifiitlv  llir  >i-.\[  >>{  calcilicati.m  and  will  ri,|uiiv  tlio  ii.-r 
(•!'  till'  saw  or  ciittinii-rnici'iis  in  sc|iaial('  il  into  s.'^MU'nt>. 

Jl  is  important  tn  sever  (Ik-  (■artila.>:c  ami  al-o  to  ennti'ui  ihe  Iki'Iii- 
«>rrlia>rc  lu'rnrc  iienetratin,!.'-  the  iniienus  nieMiliraiie;  otiierwise  a  Iroiilile- 
stiinc  ciijeh  niav  riinlei'  the  eiP!ii|ilet  inn  dl'  the  (i|ieiatinii  niorr  dilliciilt. 

Ill  (ilder  In  have  ihe  npeialit  exactly  ill  the  eelitlV.  aiul  at  the 
satiic  time  tn  >a\e  the  vnral  cnriU  frnin  iiijurv,  il  i>  well  tn  incise  the 
iiiiicniis  iiieiniiraiie  frniii  lielnw  iipwanl.  the  se\(n'(|  earlihii^cs  hc'in>; 
held  apart,  while  the  pn>itinti  nf  the  enrds  is  e\pn>e(|  |n  \  ii'w.  I>v  this 
means  they   heenme  a  ,^llide   tn   the  cninpletinll   >>(  the   nperalinll. 

It  i>  alway.-  lie.-t,  if  pnssiiile.  tn  leave  a  >mall  pnilinii  i>i  the  earti- 
la.irc  directly  hem^ath  ihe  iintch  iinsevcrcd.  'i"hi>  will  prn\iiii'  I'nr  nmre 
perfect  iiiii(rii  diirinn  (he  pi.icos  i>{'  healiiii,'.  In  nperatin-.  the  pnsi- 
linii  nf  the  cricnt hy rnid  arlery  ern>sin.Lr  the  erienihvmid  mciidiram' 
should   li!;ewise  he  reinemhered. 

W  hell  tile  thyroid  cartila.Lre  ha>  thus  heeit  opened,  il  i-  (d'tcn  dhli- 
eiilt  In  distin.irnish  correctly  the  tissues  within  the  lai'ynx.  t'arefiil 
ohserxation  nf  the  expo.seil  arytenoids,  howe\er.  in  their  tn  and  fid 
liiovt'iiieiits,  will  snuietinK"^  reinnve  the  dillicullv. 

After  ivmnval  of  ihr  ^i^owth.  for  which  the  preliminary  thvrotomv 
lias  heeii  perrormed.  ami  iKemorrha'je  has  hoeii  eniilroncd,  ilu>  cartj- 
laircs  are  hroii^ht  lni;ctlier  a-aiii  in  as  perfect  appo^iiinn  as  po.-.-iidc 
and  secured  hy  sutures.  In  a  child  these  should  he  of  ,-ilk-worin  ,i,nit 
and  loll  in  sihi.  The  skin  i>  then  .-nliired  in  the  ordinary  wav.  ( I'.ns- 
worlli.) 

The  question  of  ju'eliininary  tracheotomy  and  when  it  slmuld  he 
dniic  iiinst  he  decided  in  each  case  upon  ils  own  indi\idiial  merits. 


i% 


'j 


-I 


(  ii.\i"ii:i:  i-.w  I. 


M  I   TK  l..\i;VN(irilS. 


'I'llis  is  a  ciiiiiiiiiiii.  lull  nni  n  (hiimcroii-.  di-cii-r.  Ii  i-  uiiatlriKlcd 
liv  .sin<fiiiii('(iii.s  inliliratitiii.  tin  iiilliiiniiialcrv  |ir<i(i-,«  liciii^  cuiiliiu'd  to 
iIk'  iruicdiis  iiifiiiliiaiic  witlidiil  iiniil\iii<i  (lie  dti'iicr  ti>-iH's.  Its  chii'l' 
iiitcicst  lirs  ill  the  iiii|iairiiuiit  nr  cvcii  Idss  of  voice  wliiili  ii>iially  at- 
tt mis  its  (l(\i'l(i|i!ii(iit. 

Pathology,      'i'lic  (irst  (•iiaiiiro  aif  tin'  ainiipiinal  dilatat  inn  i<(  the 

la i_v lineal   III I-Vfss('ls.   willi  anc-t   ul   i:laiiiliilar  sctictinn.      'I'iii^  is 

i|iii('l\ly  I'ollmvcd  hy  cMidalKni  nl  -iiiini  and  ictiiin  of  iiuicoiis  mttc- 
tion.  'riic  loose  I'olds  (d'  iiMUoii^  nitnilirain'  lM'<oinc  rii^orifcd  witli 
liloo(l,  as  wt'll  as  liatlicd  in  x  ro-iiuicoii.-  di-(l:ar,L:<',  Tlic  parts  most 
alVt'clcd  arc  wliiTe  these  foMs  are  aliundaiil  a-  well  as  loosely  attached, 
a>  ill  the  arytenoid  coiiiini.--iirc  and  vcnliinihir  hands.  As  the  vocal 
cords  are  '  'i|i|ilie(|  with  tiinei|iai'ou^  ulaiid-.  their  li|ood-ve,-scls 
hccoiiie  dil-  •  itlnuit  dix  har;:e  (d'  iiineii«.     'Ihe  inllaniiiiatory  action 

rarely  exie  .ii.-  helow  the  vocal  idid.-.  and  the  e|)i<f|ottis  is  liki'\vis(! 
rarely  a  participant  in  the  di.-ea-e. 

Etiology.  —  Without     the    e\i>lellee    (d'    >oiU"    pledi-posillL'    caiHC, 

acute  laryii.uitis  docs  not  (dteii  oe(  nr.  'I'his  ll^llally  tak<'s  tlic  I'oriii  of 
olisfriictive  interference  with  normal  re-piration.  cither  from  intra- 
nasal lesion  fir  post-pliaryiiLri'al  disease.  What  lliese  palholoLrieal  eoii- 
ditions  are  have  already  iiccn  dwelt  upon.  It  will  siillice  (o  say  that 
hy])ertrophie  conditions  (d  the  upper  hreathiifj-passaires.  wlien  siilVi- 
cieiit  to  j)rodiiec  oral  rcs|iira;i<in.  may  heconie  a  predisposiiiLC  cause. 
The  same  may  he  said  of  ciironic  catarrh  of  the  pharynx,  and  also  of 
atrophic  rliinitis,  imismiicli  as  it  deprives  the  ;iir  of  rojiiralion  of  its 
necessary  moisture. 

'riie  immediate  cause  of  tin  disease  is  freipieiitly  exposure  to  cold, 
.i,'ettin!i  the  feci  wet,  siiddeii  chanires  id'  lempeiatiire.  too  hasty  coojiii;; 
of  the  liody  duriiiir  jierspiratioii,  etc. 

It  ooeiirs  at  any  aire  of  life.  Init  in  men  more  than  women,  owin^j; 
to  the  greater  exposure  incidental  to  their  lives. 

Inhalation  of  irritating  vapors,  such  as  chlorine,  ammonia,  etc.,  or 
excessive  smoking  may  give  rise  to  it.  The  internal  administration  of 
(362) 


ACITK    I,AUVNUIT1S. 


yoij 


ind.  [int.  ill  liir^'c  (|n^(•s  Will  iil«i'  ill  (•  I'taiii  (Msrs  |»r(Mlu(t'  IiirvM^ral  in 
tlainiiiatioii. 

Amitlicr  caiisi'  (Hiitc  rimirunii  aiiKUii,'  vnicc-Uifcrs  is  overstrain  nf 
tilt'  \ni(f  ill  siniriiiir.  [nililic  :-|H'akiii,ir,  «'ti'. 

Symptomatology.  Tin'  ninst  imtii  raiilc  <yin|.tiini  is  liciarscnos  in 
various  dc^rrccs.  It  is  nuc.  Iinui'vc',  \  <v  cniniilt  Ir  a|iliiiiiia  tn  ociiir. 
for  till'  siinplc  rraMiii  ilmi  it  ici|iii!cs  iimic  or  li>s  inliltriilicui  nf  tlif 
arvlcmiiils  or  vocal  cords  to  |iiddii(c  alisoliitc  loss  ol'  voice;  and  tlli^ 
woiiM  place  it  under  tlie  licaditii,'  of  larvii^'itis  i^n'avior  instead  cd'  larvii- 
irilis  niitior.  or  simple  larynjilis.  Willioin  indltralion  rially  exist-, 
the  \iiiee  ciiii  alwav-  lie  sipiiiidcd  liy  inakiiiix  extra  ciToit.  <a\e  in  those 
cases  where  ilie  iierviJiis  eleim  ni  ha»  entered  lar<re|y  into  the  history, 
and  in  these  the  iim'  (d'  the  laiyiiu'o>cope  should  nialeiially  aid  in  the 
diai,niosis. 

hiseoiiifoil  i>  ii-iially  in  the  rnini  of  sdiciK  s<  rather  than  pain,  and 
partak(s  <d'  the  dry  and  -li'^ht  ly-lmi  niiiLf  chaiin  I.  r.  '["here  is  no  diHi- 
eiilty  ill  re>piratinn.  hiil  frei|iii  inly  a  har-h.  irritatiiit:  thioal-coiiudi  in- 
creases the  ;,fencral  nialaise.  'i  he  coii'^li.  too.  is  out  ni  piopoition  to 
the  sniall  anioiint  id'  expeetoral inn  which  is  at  first  discharL'ed  from 
the  inllained  throat.  This  secret  imi  increases  somewhat  as  the  disease 
advances,  'riieic  may  he  .>-liL;ht  diHiciiliy  in  swallowin,:,'  solid  food, 
while  hiand  diet  will  slip  down  withciiit  ell'url. 

Of  lever  there  is  tint  little.  No  distress  id'  the  <,'eneral  system  aiid 
practically  the  disease  re.-olves  itself  into  tiniporary  hoarseness  ae<'om- 
paiiicfl  hy  more  or  less  irritation. 

Diagnosis.-  I'' reijiii  111  ly  the  aluiipt  on>et  of  the  disease,  with  the 
charaeteristic  voice,  is  (|iiile  siillicieiit  to  eslahlish  the  diaLnmsis.  Still. 
there  are  many  tliiii;/s  wlii(  h  may  jimdiiec  hoarseness,  and  it  is  lietter 
when  possihle  to  nial<e  the  opiiiinii  sure  hy  the  use  of  the  laryn'_ro.'cope. 
The  chief  aim  in  iisitiLT  it  should  he  to  examine  the  vocal  cords.  If 
they  are  smooth.  allhoiiLili  reddened,  opcnin.:  and  (dosin'j  evenly,  and 
are  without  thiekcnini^s  nr  indcntatimi.-  iipi  n  their  horders.  (he  diai:- 
nosis  may  ho  tolerahly  sure.  The  hlood-vesscN  upon  (heir  siirfiices  may 
he  liiirliei  t'olored  and  more  prominent  than  usual,  with  the  cord- ."^till 
white  and  jrlistenini:;  or  the  whole  surface-  of  (he  cords  in  a'^i^'ravated 
cases  may  he  hypcra'mie.  .\i  the  same  time,  the  mucous  linin>,'  of  the 
laryn.x  will  have  a  hright,  con'iested  line,  which  in  some  eases  may 
culminate  in  thickcninj?  of  the  intorarytonoid  commissure,  preventing 
entire  closure  of  the  cords. 

A  red  or  pink  color  of  the  vocal  cords,  however,  is  not  always  a 


Hi.- 


.{»;  I 


iii>i:  \-<i:^  or   i  in.  i,.\in  n\. 


%!  i 


iliugiin>iic  iiidiiiiliuii  111  liii\  ii;;iti.«,  imr  I'lllur  i>  a  iMiirlv-wliilc  coiidi- 
tiun  a  sure  si^n  of  a  tiniinal  larynx. 

'I'liis  was  hrniij^lii  nui  jirumiiiciitly  \>\  llcniif,'  at  the  nrcnt  Med- 
ical ('(•ii;:if>.-^  a(  War.-aw.  lit'  ,<ai<i  llial  not  iiirri'i|iH'ntly  tlic  pearly 
wliiti'iics.s  was  fati.-t'd  li\  iavors  ol'  lliickciird  ('|iillirliiiiii,  and  lliat 
owiii'is  (d'  Miral  (iiiil,-  nf  tins  ciilnr  would  ('(uih'  Io  the  larvn^f<)lni,'ist  I'^r 
IrcatiiKiit    I'nr  Mical   iriiiddi-.  ulidf.  dii   llir  ullirr  hand,  xnwf  (d'  tin: 


l>est  sin;:('r.'«  had  I'ld,  ratarrhal-lnokini 
tioloi.st.s  III'  knew  (d'  had  sliiihllv-r 


ciiid 


»»nc  (d  the  liiu'st  ladv 


('(I  ciuil-  hcluic  Miiinni',  and  very  ro( 


1 

oiU'S  al'ti'i'.  In  tlu'Si'  cases  all  llie  syiii|ilniii-  and  ^i,^'ns  availalile  ninst 
add  the  lai)  n::n|ii;,d.-t  in  aniMiiv  .il  a  cnirni  dia^no.^i.-. 

In  ciiniiiariiiL:  hdai-eiiev-  li'iin  ihi>  di>(a>e  with  that  piodneed  liy 
iillicr  llndal  all'eetinn>  il  -hnuld  he  rennni'ieied  lliat  the  h<)ar>ene.--s 
(if  lar\ni;eal  lidiereuhisis  i.-  Mill  anil  v.eak,  and  that  (d'  s\|)hilis  i.s  harsh 
and  '.^latinL:.  whdi'  thai  lr<ini  aeiiie  i  ..unination  is  even  and  firm,  al- 
thonijli  il  may  he  ra^pin^  in  inne.  In  IkiiIi  the  I'liriner.  as  well  as  in 
niali,uiiaiil  di.-ease,  and  when  nenpa-ins  aie  present,  the  Imarsoness 
eiiiiies  mi  ::radiially  i<iid  .-lowly,  wilhoiil  leiideiiey  to  inipniv  enicin, 
while  the  disease  under  eoii>ideration  is  .-ell-liniited  in  history. 

Prognosis.- -I I  is  imi  din,i:erons  to  lil'e,  and  it  runs  a  conrse  vary- 
ing' lidin  a  lew  days  tn  a  eoiiple  of  weeks.  'The  inipairineiit  id'  the 
fiuu'tioii  <d"  voiee-proiliiciiiiii.  pail iiiilarly  in  ^iIll;l  r-  and  jmldic  speak- 
ers, is  till.'  nm.-t  iniporlaiil  i  nii>ideratioii  in  le^Mrd  lo  it:  another  point 
is  the  prohahilily  id'  it^  reiuiiinee.  owinu  in  the  presence  of  the  pre- 
dispo-iiiL,''  causes  already  iianud.  .\ny  tiinlency  to  extension  (d'  the 
disiase  down  into  the  trachea  or  hroneliial  tiilu's  ninst  akso  owe  it.s 
ori^dii  to  the  impaired  naso-pharynireal  respiration  rather  than  to  laryn- 
geal inllammation.  The-e  .-hoiild  all  pnini  to  ihe  importiiiicc  id'  re- 
moving' any  stenosis  that  may  oeeur  iii  any  part  of  the  upper  re^pira- 
tory  pa.--aL:e>. 

Treatment.-  As  tlii>  is  a  local  ilisiase.  attended  hy  so  little  fehiile 
(hstuihance.  1  helieve  larjiicly  in  relyiiitr  upon  local  treatment.  This 
should  not,  however,  he  conlimd  to  the  larynx,  hut  slioiilil  eonimence 
with  the  none  and  nasd-pharyiix.  W'hatcvci'  is  the  immediate  cause  of 
the  disease,  examination,  as  a  ride,  will  find  more  or  less  nasal  steno.si.s 
in  one  or  hoth  pa.ssa^'cs.  In  these,  if  treateil  at  his  oHice  hy  the  .sur- 
geon, a  l-jjer-cent.  solution  of  cocaine  should  he  thrown  np  each  nostril 
by  an  atomi/er.  .\  small  ([uantity  will  sulliee;  and  in  two  or  three 
minntes  tlie  astringent  elfect  of  the  cocaine  will  bo  noticeahle.  The 
patnlous  condition  of  tlie  jvassages  will  he  increased  and  the  ])atient 


.\ri  ii;   i,\i{VN<iM  i>. 


:{i:r> 


iiilc 

Ilia 

■nee 
-(>  of 
lusis 
;iir- 
<tnl 
iroe 
The 
lent 


•  Jill  lildw  out  I'lVfly  iuiy  acciiiimlatioiis  wliicli  liy|)t'rlro|iliic  rii;iorg«'- 
iiu'iit  iiiiiy  liavc  iiilowi'd  to  HjitliiT.  An  iiiipottaiit  dul  imw  to  lir  aiiiii'<l 
at  is  to  kiTj)  tln'  passa^ri's  ()|k'I1  a.s  lon;^  us  possiltic,  lliiis  ifstoriii;,'  nor- 
mal i('.«|iiratioii  and  I'afililalin^r  lai'vn;iial  rccovcrv.  Spcakinu'  J'liliroly 
from  my  oun  cxprririicc.  i  would  ajiaiii  rclVr  to  the  cjliciciiiy  in  jiro- 
l()ii;.niiLr  tilt'  astrin;,'t'iit  alVccl  of  cofaiiii'.  wliii  li  1  Iimm'  imiiid  tlic  ap- 
plicaliiiii  iif  l-per-cfiit.  xdiitioii  of  iiifiitliol  m  alliolriic  to  ponsoss. 
Wlirii  tliiowii  into  tliL'  nasal  pussajit's  liy  an  iitoiui/ii'  iiiinirdi.iicly  after 
the  aiisorpiioii  of  ilio  cocaine,  it  not  ttnly  -l  miiihiti's  tiic  .-nreiing  cells, 
tlnis  relii'\  iii,^'  the  eiiL:or;:emeiit,  hut  al.-o  coiiiit»'iacts  the  depressing 
i'lrccl  which  the  cocaine  itself  produces. 

.\c\t,  the  pharynx  ^Imuld  he  spra\(d  niil  I  ii  i  ly  with  an  alkaline 
solution.  >ii(li  a-  linlielTs.  This  will  relieve  hi. ill  |)liaivn\  and  larynx 
of  any  hypeisec  reiioii  that  may  he  preseiil  If  the  iniyiu  is  found  to 
i)e  \cry  niiieh  con.L'este(l,  a  1-per-ceiit.  solution  of  ccuniie  should  also 
he  thrown  into  it  tliroiij,di  the  down  tip  of  the  atonii/.er.  The  coii;,resled 
condition  in  a  \ery  few  iiinuK  nts  is  Mimcv  hal  iidieved.  The  treat- 
ment immediately  following  this  depend-  ii|inii  the  h  ii;:ili  ni'  time  dur- 
ing whii-li  the  disease  has  heeii  in  e.\i>tei)ic.  If  aihice  is  sou;;!it  near 
the  onset  of  the  symptom.-  a  similar  l-nci'-ccnl.  solution  of  monthol 
in  alholene  as  that  alreadv  appliecl  to  the  nose  will  have  a  good  elFoct, 
jind  a  spray  of:  — 


I.     Ii   Tliymol    , 
Mcntliol 
AlbuJL'iiu 
M. 


.00 


iipplied  hy  the  jiaii'  nt  to  the  laiyiiv  every  twn  nr  ihree  hniir.-  until  he 
again  retiuires  to  see  the  phy-iiian,  may  he  |neMrihed. 

If  tlio  inllammalory  Cdiidilion  is  of  loiiLter  stamliiig  and  well 
estahlished.  the  cocaiiK'  sidulioii  may  Ik;  thrown  into  the  laryn.x  a  lit- 
tle more  freely,  and  followed  immediately  hy  the  ap|tlicati(m  of  a  v-per- 
cent.  snliitinii  of  niliiite  of  silver  hy  iiicans  of  the  liirvii::eal  cottoii- 
hohler.  .\  similar  solution  id'  the  nitrate  loiild  he  ap|iliiil  hy  atomizer, 
and  liosworth  recommends  it  in  this  way.  After  the  application  of 
the  silver  the  jiatient  >lioiild  carry  out  the  liome-tri'atmeiil  as  already 
<lescrihed,  returning  evi'ry  second  day  to  have  the  ajiplication  renewed. 

In  cases  in  which  Ujion  examination  we  find  some  hypertropliic 

1.     3  Thymol  f?r-  "j- 

Menthol    >?r.  x. 

Aibolene   5ij- 


f 


it 


M. 


M 


36G 


iiisi:am:s  ui    iiik  i.ahvnx. 


Ijj'   i! 


it 


liiisiil  .>|-  |iliiii\  iil;i';iI  1i>>iic  (M(ii|iviiii;-  a  |iriiii,iiv  ciiUMitivc  icliilioii  to 
the  liirviiiiitis.  till'  i|ii('^tioii  (iT  ii(l\  isiiliilit  y  nl'  (i|H'r;it  inn  iiri-cs.  Some 
liirvii^ioldiii.-ls  liclic\c  ill  \vititiii'4  until  llir  hii yniriiil  ilillicnily  has  siili- 
sidcd  licrurc  (i|icriil  iii^.  Ollicis  liclirM'  in  ii|i(ial  iiiu'  ii-  snnii  as  tin! 
loKni  i.-  (ili.-ci'\('il.  lii'lii'V  iit.Li  1 1  I.I  I  till-  ilx'ir  will  |ii<iiliiic  a  cnic.  In  my 
(iwii  niiinl.  it'  llific  i>  liill*'  nr  im  |r\ir  in  cnii-riinciicc  nl'  llic  laryii- 
^iti.-.  the  lallcr  i>  the  plan  llial  1  iiidrr  in  lnllnw  ;  and  I  have  never 
KiKiwii  II  In  lie  |irndiiel  i\('  nf  e\  il  re~iill-  Si.nie  iia-al  and  |iliaryiii,'eiil 
<i|)erat  inn-  are  allended  li\  nmre  nr  Ic--  lilicdini;;  aii<l  il  is  well  In 
ri'iii.iidier  ilial  tin-  lia'iunii  lia^e  nia\  have  a  sidati\e  ell'ecl  ii|inn  the 
iiillaiiied  lai\  n\.  Winn,  lin\\e\  er.  |  Ik  ic  i-  niiieli  filn  ili'  act  inn  nr  the 
larvnmli-  i>  -e\ei'e.  Il  I-  al.\a\-  lielliT  In  |in>i|Miiie  n|M'ralive  iiieasiires 
until   alialeiiieiit    ha-   lak(  ii    plaie.      In    llie   .-aiiie    \\  ay   ,i;al\anneaiilcry 

n|ie|'at  in||>     Wllllin     the     nn-e    -hnllld     lie     |  in- 1  |  in  lied ,    nil    aeecnilll     <  d'    til" 

(rdeina   and   -lenn,~i~   wIikIi    lhe\    -nineiinn-   Ic  in|iin'anly   ]iindiiee. 

When  the  inllaniiiialni  v  aclmn  i>  allended  li\  niiieh  re\er.  and 
the  lai\  ii,i;eal  ii  rilai  mn  i-  \  ei  v  lt.  al .  a  <  lire  can  he  evpediied  hy  .-teaiii- 
inlialatinii  riei|nenllv  re|iei:ted.  ur  h\  eniiliniiit.'  the  jialieiit  In  a  warm 
rninn.  -iiieharLied  with  inni>tiiie  e\a|)nra|ed  \yntt\  aiit:se|ilie  snlntinti- 
(if  nne  Inriii  nr  aiinther.  W  nil  llii>  the  ailiiiiiii-1  lai  mil  n['  lineliire  nf 
acnnile.    I   drn|)  per  Imiir.  i-  >till  a   lavnrile  leniedv    with   iiiaii)'. 

When  enllllnenienl  III  the  hnll>e  JMcnnie.-  Ilece-vaiy.  I  prefer  llle 
ilpplieat  inn  In  the  lleik  nf  ('i|nal  part>  nl'  iili  \  edil  and  nil  nl'  I  lllpelll  ine. 
with   an    niilside    wrappiii;^   cd'  alisnrheiil    entlnii.    In   the   (ddd'ashiniied 

inethnd    nf    pi  Ml  1 1  lei  111;'.       ( 'nid    paekill;.;    tn    I  lie    lleek    is   alsn    prndllelive   nl 

a   sedative  ell'eil    iipnii    lln     inllained    lai\n\. 

It   i<  dnidili'id   ir  heiielii   can   he  deri\'ed   I'min   the  ii-e  nf  <iidinarv 

ast  rill^U'ellt    |nZellL:e>   in    ihi'M'   ea-e-.       'rhr\    ilii    linl    en|ne   in   eiilltael    "vitll 

the   interlar\  iiL;'eal    niiienii~   nn  mhrane.  and    Imw   a   >liuhll\    a-l  rinu'eiil 

ell'eet  llpnll  llle  pliai\n\  call  iiillelil  the  runner  !.-  dnlihirnl.  W'liell  the 
eliii'l'  inL[iedienl  (d'  the  |n/.eiiiie  i-  (if  a  vnhitile  iiatiire  tile  ease  is  dil'- 
I'erellt.       'rhi>    may    he   -aid    id'    niellthnl    !n/ell'je-.       'I'liey    tint    nldv    InM.! 

a  Ineal  inlliieiiee  llpnll  the  pliary iiu'eal  wall-,  hiii  tie'  \apnr  nl'  the  men- 
tlinl  is  emit  innally  hrmiLihl  in  cniilai't  with  the  lunenii-  inemhrane  (d' 
(lie  lar\n\',  prndiieiiiL:' a  e<inlin.r.  ii-  well  a-  a-l  riiiiieiit.  eU'eii. 

One  impnrtanl  pnini  dnriiej  treatmeiil  i-  In  in-i-|  npnii  a-  little 
use  (d'  the  vniee  as  pn»ihle.  The  /iriiiiii'  rid'  slimild  also  he  rcLiuliitcd, 
ami  judicious  cITorts  made  in  avoid  any  repetilimi  (d'  evposiire  to  cold. 
'Pile  ini|)ortiuU'i'  of  iilisoliite  and  eniitiiiued  nasal  respiration  should 
likewise  he  impressed  upon  (lie  mind  rd'  Ilie  pidient. 


[■      !' 


(■ii.\i'i'i;i;  i.wii 


M  \ w:  \..\\[\\c,\\\>  ni'  (  iiii.i)i;i;\. 


I\  cillK  lll'i'  llclllr  l;ll\  IlLilM-  I-  llhUi'  llrcjiM  Ml  lliilM  dlirillL;  ;|(|lllt 
V<'lll>.  nwillL:  t'l  IIk'  'jrlHTilllv  |(mi-c  ,i1  I  Milnilrll  t  iil'  lllr  lllllrdll-  IIHIII- 
lilillH'  .-IIhI  111  it-  lllir<M-ci|  \;l~clll;inl  \  .  'I'lli'  lllll;illllll;lt  HM.  ulllrli  i< 
rit'(|iiiiil  l\  phiii  \  iii;i>;il  III  il~  iiiiLiiii.  iii;i\  cAlrinl  incrciv  in  llic  ii|i|icr 
|icirliciii  nf  ilic  l:ir\ii\  iir  iii;i\    ]i.i-~  ilnw  nw  ;iril.  ;ilTi(  i  iirj  iIh'  iiil  i;il;IiiI  l  ir 

rc^inll.  'Ihr  |(i(i-c  illlilihllji'lll  (i|  ihc  11111(11-, 1  |ir||||ll.-  ol'  ,\  (crlillll 
illlHUinl  'i|  inlill  nil  mil  Ullllnlll  |irl|i't  ml  inu  ilrc[i!\  inln  \\\r  -.IllllllllinU^ 
I  i,--l|i'.   I  illl.-lllL;    till'   ill  III  I II  ill-    -\  III  I  I'll  II  I-    W  hirll    -II   I  ill  III    I  ice  Ml'    111    VdllllL; 

cliililrni      'I'lic  ca-i-  iliMVr  in   -i\ii'il\,   llir  iiiiMiT  mir-   liriiu  ili-liii- 

^t;lli>llr  '  llliTrK  li\  ;l  ll;ir-Il  riillLlll.  lilf  IIHU'i'  -r\i'lr  ii||i'-  liV  M  sIlllli'Mt 
S|tll.-llliMllr  I -Id- 1  ire  111'  I  111'  -lilt  '  I-  1 1  III- ill;;  I  Ih'  ;lit-  nf  i  i  iIIl:  ll  1 11 '^  II  ml   lili'lll  ll- 

Iiil:'. 

Patholog'y.  In  lln-  ili-cn^c  uc  Ikim'  In  |iri;iiina  nf  llir  liir\  iilk  iil 
iiiiicii-ii.   till    niinnlr   \i--rl-   Ih'iiil:'  l^iuliciI    with    IjIihuI  uml    the   lun-cIv 

illt;icll(i|  inrllllillllli'  liclll;j  -Witllill  In  II  llinri'  iir  li'--  rNliIlt  li\  I  \  111  |  illlll  ir 
prcs-lllc.  W'lli'll  riilllillril  In  lllr  -  II  | )  I'll  L' |i  ill  Ir  |liirlliii|.  llli'  1  1 1  llll  ■  I'llrt  H  1 1 1 
is    illlliti'il;      wllrll     inriil'^liil  t  K      It     llliiy     lie    -r\i'|r    11-    Ucll    ;l-    cVtrll-iM', 

iiliiinsi   rliisiiit;  llif  Iniiini  nf  iIh'  irirmij    rrL;iiMi   uml   iirmimiiri  -cmtc 

liir\  llliiili   <lrl|ii>i-.      Till'   -\wlliiu;   nf   lllr    |)lllt-    I-   :lluil\-   I(I|||1iimI    In   till' 

ir.iiciiii-  iiii'iiilirniic  il-fll'.  iiml  ilnrs  iml  iinnKr  llir  -iiliiniicnii-  li-.-iir  iis 
ill  iiciitr  ii'ili'inn.  ;iml  i-  |iriili;ilil\   ilnr  in  ilir  jirf-cin  c  nf  llir  l\iii|iliiit  H' 

\C'>-M'I-.  wllicll  ill  r;ill\  \i;ir-  In', If-  -i  i  1  111  |  mil  ;l  li  t  ;i  |i;llt  l||  lllr  ;l!mln||lV 
III    thr    tlll'nill. 

Etiology.        'I'll:'    |lli-rmr    nl     1 1  \  |  ii  ■  I  I  I  1 1 1  il  I  \     n|     lllr    I  \  11 1  1 1 1  111  I  ir    ll--nr- 

dl'  t  l,r  I  lirmit  i-  l'rci|i;ciit  l\  ii  |ircili-|in-iii;^  niii-r,  mil  (inl\  rmui  I  Ih'  Icm!- 

(>lll'\'    In    l\  m|ill;ll  il'    inlllllllllllll  mil    imiili'lltili    in   niris     Illr.    luit    ;ll-n    I'i'nill 

lllr  nil-ill  sli'iiii'-i-  uliii'li  I'liliirLii'i!  rniiiiiil  nr  |iliiii\  iiunil  |(iii-il>  -n  i'rc- 
i|ii('iil  iy  ciiiisi'.  'I'lic  iimiil  II -liri'iil  liiiiL'  \\  Il  llll  I'lillnw  -  iiiil-  in  |)riii|iii-iiiL:' 
Iiii\  iiuciil    iiriliit  ii'ii. 

'I'lii'  iliscii-i'  i-  |ir(ili;ili|y  iimir  iniiiinnn  nnmiiL;  i||-iiniiri>|ii'(|, 
ricjjicclcil.  ilj-cloliinl  ciiiMicii.  Still,  it  rn'(|iiriit  ly  ncciiiv  ill  Mppiir- 
ciilly  s(r(>n<j  iiml  xiuornii-;  ones.  I'mlmlily  in  tlirsc  ;i  ciirfriil  (•Xiiiiiiiin- 
(icm  would  rcvcnl  ii  lyiiipli;itic  tciKlciicy  imt  at   lli-t  iiuticcd. 


'M',H 


1)Isi:asi:s  ok  tiik  i.akvnx. 


'J'lie  oxi'iliiiLr  ciuiiio  is  usually  idM  tir  I'xpuj^urt'  to  ohiin,ijc'al)lo  and 
uneven  teni])eratures.  Childri'n  often  ^,^'1  overheateil  while  playinj^ 
and  will  sit  ilown.  cooliiii:  the  body  unequally  uliilc  the  skin  is  still 
])ei's))irin;f.  'I'lie  eonse(|ii('iuc  is  ;hat  the  Mood  is  driviii  I'lnm  the  sur- 
face to  the  internal  tir^aiis.  iiml  the  throat,  liahlc  as  it  is  to  catarrhal 
aU'eclidMs,  is  tlu'  or^aii  iiil.-i  likely  lo  he  alTected. 

I'xiys  siill'cr  more  J're»[U('nt]y  linni  this  dism^r  than  uiils.  jirnh- 
alilv  nwiiiL,''  to  ,i;icatei'  exposure. 

Symptomatology. The  niihhr  tonus  of  ;iiuic  laiyn,:;itis  in  chil- 
dren usually  ((Uiiniciii  (•  m  luiite  rhiiiiti-,  the  inlianiinatory  action  cx- 
tcndin<i  down  to  the  pharynx  and  ihr  ^up^al:lllllic■  jjortimi  (d'  the 
larynx.  There  will  he  druu'ss  ;ind  ii'iilatinii  of  ihe  throai.  with  sli.iiht 
hoiirseness  and  >li'ididiuis  couixh.  'I'lic  more  si\ci'i'  ca-c-.  ihose  to 
which  the  term  spa>inodic  cidup  is  >(i  ccimmoidy  applied,  are  more 
likely  to  arise  in  cases  of  tonsillni'  enlaru'emenl.  the  larynu'eal  symp- 
toms arisint,^  I'ldm  direct  irritation.  'I'lie  constitulioiiid  di>turl)ance 
is  jjreater  in  the  latter  than  in  the  former:  and  the  fexcr,  whitdi  is 
sliglit  wlu'U  the  upper  larynx  is  aiVeeli'd.  is  likely  to  iiecome  severe 
when  the  suhLdidlic  reixion  is  the  seat  of  the  disease.  It  is  only  in  the 
latter  that  laryn.ircal  stenosis  is  likely  to  be  at  all  severe,  lloarseiu'ss 
will  be  of  a  shrill,  metallic  character  at  lirsl.  <,n'adually  a>snining  a 
liarsber  tout'  and  in  sonu'  instances  endinjr  in  aphonia.  C'ouirh  attends 
this  disease  from  the  first  and  is  stridulous  ainl  croupy.  with  nocturnal 
exacerbations.  'J'he  attack  usually  ctmics  on  in  the  nii^ht-tinic,  and  the 
child  may  coui^h  for  a  ([uarter  of  an  hour  before  it  can  obtain  relief 
by  the  expectoration  of  a  little  mucu-.  Sometimes  the  exacerbations 
are  re])oated  seveial  times  durini.''  the  niiiht. 

The  disease  is  more  |irevaleid  duriuir  the  cold  and  dam])  months 
of  the  year,  and,  haviuLT  once  oi'curred  in  any  child,  is  liable  to  recur 
again,  uidess  the  obstructive  lesions,  which  may  have  triven  rise  to  the 
first  attack,  have  been  removed. 

Diagn*  is.  -  -  l.arynnoscopical  examinatitin  in  youni,^  children  is 
usually  very  dilbcult.  Still,  in  some  instances  it  can  lie  accomplisluMl, 
and  will  reveal  the  liyperaMiiic  and  infiltrated  eomlition  of  the  inntu- 
larynx.  In  these  cases  Kirstein's  antosco])e  in  skillful  hands  should  do 
good  service,  and  under  chloroform  should  be  particularly  easy.  Ac- 
cording to  Kirstein,  it  can  be  done  without  the  use  of  the  anivsthetic. 
but  is  necessarily  diilicidt  and  somewhat  dangerous,  owing  to  the 
struggles  of  the  child. 

When  visual  examination  of  the  larynx  cannot  be  made  by  either 


Arm:  i,.\KY\(ii  lis  OK  ciiii-nitKN.  :!•!!> 

inctliod,  it  makes  tlic  diiii^ninsi?  iikiM'  ilillicult,  as  lli<'  unliiiaiy  syiiipldiiis 
bear  soiiH'  rc>('iiil)lanc('  to  those  of  ineiiihraiioiis  ernup  or  laryni,'eal 
iliplithei'ia.  Si  ill,  the  severer  diseax'  is  attemlnl  liy  imieh  si'veier 
symiitniiis,  such  as  hijilier  tonipcrature,  more  eomplele  aphonia,  more 
noiseless  eonuh.  and  irreater  phy^^ieal  ])rostrMt  inr.  Mn-t  writers,  at  the 
present  time.  ai;r<'e  with  lh(>  idea  ol"  the  iilenlity  nt'  p-eudmnendirannus 
croup  with  laiTnLiea!  diphtheria;  and  it  mr.-'i  lie  reiiiemliered,  in  the 
way  of  iliajrnosis.  that  in  the  latter  the  exudative  disease  is  striitly 
proirrt'Si-ive,  while  in  the  so-called  spasmodic  (•r(Mip  the  iincturnal  e\- 
aoerhatinn>  are  the  most  important  feature. 

Prognosis. — 'Ihis  diseast>  is  not  usually  dan^^ernus  to  life,  'i'he 
nocturnal  exaeerliatioiis  aie  the  only  indications  which  >h(udd  tause 
alarm.  I'sually  they  increase  in  severity  for  two  or  thiec  niirh.t.*. 
Then  they  ahate  ami  soon  disappear,  the  hai'shness  of  tiMie  and  throat- 
irritation  j^radually  passin;-'  away.  The  disease  may  l)e  e.xtendi'd  out  to 
two  or  three  weeks,  hut  usually  it  is  of  .shorter  duration.  Occasionally, 
thou^di  rarely,  death  may  ri'snlt  froni  the  suliiilottic  ledenia. 

Treatment. — .\s  soon  as  the  decided  hoarseness  ov  croupy  i.iu^h 
occurs  in  a  child.  iiulieatinLi'  the  presence  of  acute  laryngitis,  he  should 
he  placed  and  kept  c(Uitinually  in  a  temperature  ol  ainuit  T<i''  !•".  it 
would  he  advi.-ahle  to  have  moisture  continually  evaporateil  in  the 
room.  The  bowels  should  be  moved  l)y  a  laxative,  ami  mild  soft  nour- 
iplinunt  -hould  be  yiven. 

For  internal  admini-itration  minute  doses  of  aconite,  with  car- 
bonate or  muriate  of  ammonia,  do  excellent  service,  as  they  relax  the 
pores  of  the  skin  and  stimulate  the  tbro.it  to  mild  secreti(Ui.  The  I'ol- 
lowin<r  are  suitable  |M'eparations:  either  of  these  mij^ht  answer  for  a 
child  four  or  llv(>  year-  old:  — 

1.     II    Mur.  aiuninii ,"> 

i'v.  ai'oiiitf    2.') 

(ilyc'criii    4 

.XiiUiOii  ad  aO: 

i 

-M.     Sip.;    Olio  teaspoon  fill  every  "lie  or  two  liours. 

1.      li    Mur.   iiminoii ;,m-.   \  iij. 

'I'r.  lU'onito  ;;l  t .  iv. 

(ilyeeriii    .ij. 

.\ilMani    iiil  ,^j. 

* 


:ii 


ri 


I:   .), 


IU(»  |)I>i:asi;.'«.  oi-   mi;   i.auynx. 

1.      B  Carbon,   iiinmnn 14 

'I'r.  iifonilc    12.') 

(ilvccriii     4 

.\(|Uillll     iltl   ."{0! 

M.     Si;;,:    One  lt'ns)i<i<iiil'iil  cvciy  "iif  »ir  two  li<>iir«. 

I'"t)r  t'Xtcriiiil  ticiiliiiciii  1  like  iidlliiiii;  lu'ltrr  iliiui  ii  stiimiliitin^' 
ciMdllii'iit  ii;i|ili('iili(iii  to  tile  neck  nl  ciiiiiplKii'  liiiiiiu'iit  mihI  olivr-oil, 
('(jiiiil  |tiirls,  (»r  nil  III'  tiirpciiliin'  :iiiil  olive-oil  in  like  proiiortioiis.  'This 
.-lidiiid  be  ;i|)|ili('(|  uilli  llic  Wiinii  liiiml  to  llif  iH'ck.  llicii  ;i  smij:  l.ivcr 
ol'  iihs(irl)('Hl  ciilldii  w  iii|i|)i'il  i<\cv  it  iroiii  cai'  tn  car.  \\\  its  wiii'iiitli 
il  |iripiii(it('s  senile  |i('i>|iirati<iii,  and  lliii>  drplftcs  Irdin  tlic  pai't.  wliilr 
it  all'oid.s  ca.-f  anil  ciiinrnrt  to  the  iiillaiiicd  tlirnal.  'I'lic  iKntiiriial  at- 
tack,>^  may  he  rdii'vcd  liy  a  Imt  >t('am-inlialat ion.  and.  when  tiiis  Tails, 
the  inluilatimi  n{  a  IVw  di'ii|>>  nl'  (liloi-nroi-m  will  soiud  iiiics  clicck  tlic 
f.xacfiliatioii. 

.\<  I  111'  (I  did  ill  1 1  HUM'.-,  tlic  tliickiics-  III  t  lie  til  mat  drc-.-iiiu  sin  mid 
lie  made  L:iadiially  le>>.  and  care  slinidd  In  taken  aiiain-t  Inn  eaih  an 
e\|in<iii'e  to  cnld. 

W'licii  ill  M'\ere  case.-  all  ntlicr  measures  Tail  tn  t;ive  relied'  tn  the 
little  [lalient.  resort  may  lie  had  to  intuhatinii.  l'rnloii,::'ed  use  of  tlie 
tulie  will  not  lie  rcijiiircd.  a>  il  i>  so  ri'ei|Ueiit  ly  in  eases  nT  diplit  lieria. 
the  insertion  of  the  tidic  fur  a  few  liiiur>.  nr  a  day  nr  twn  in  extreme 
casos,  Iti'iiij,' all  that  would  he  needed.  In  mi  mild  a  di-ea.-c  intiihation 
is  nndouhtedly  |ir(deralile  to  the  more  serinii.-  operatinn  of  tracheotomy. 

.\fter  the  recovery  of  the  child,  wlieii  the  disea>e  owes  its  primary 
<iri,iiiti  to  lymphalie  hypertrophy,  tlii.-  should  he  treated  aeeordinu:  to 
rides  already  laid  dnw  n.  and  iiy  thi>  mean-  an  end  put  tn  any  tendency 
t(>  feeurrciiec. 

I.        II     (iOllllll.    Mlllinilll xry,    vj. 

'I'r.  aiiiiiitc   ;;ll.  iv. 

( ilytTiiii    ,1). 

.\i|iiMiii    ml  .^j. 

.M. 


.1! 


cjiAi''ii:i{  i.wiii. 


;|: 


ALTTK  (KDKMA'iOrs   I.AUVNCUTIS. 


Aci'ir:  iiilhiiiiiiiiitidn  of  tlic  liii'viix.  iitlcinlrd  liv  irdcniii.  iin-  Inm^r 
\)Ovn  (IfSfiilicd  liy  writers  uiidci'  a  diversity  nf  iiiiiiu -.  'I'lic  U\r\>  iliiil 
it  is  ail  ('Xr('c(liii;il_v  acute  iiillaiiiinalinii.  lliat  the  iiitlaiiiinal  imi  ,i;<ies 
(lecper  than  tlie  iiuieoiis  iiieiMliiaiie.  and  lliat  it  i>  attciideil  hy  ~\\\>- 
iiuicoiis  iiililtratioii  arc  suHiciciit  to  make  the  ahoxc  tith'.  cho-cn  mit 
of  tlie  many  it  hears,  (inc  lliat  at  h'ast  is  applicalile  to  the  disca-i'. 

Pathology.-— The  m(ni)id  ehaii;:cs  are  indicative  (d'  acute  \aMidar 
tnrjiesccnee.  more  rapid  in  luiinalion  than  in  simph'  acute  laivni;itis, 
ami  attended  hy  extension  to  the  >uhniuc()ii>  ti>-ue>.  with  almn.-l  im- 
mediate serous  iiililtratioii.  'I'his  occurs  most  exteiisi\clv  where  the 
mucous  inemhrane  is  loos(dy  atta(li:'d.  as  in  the  re;iion  of  the  \cii- 
tricular  hands,  the  arye|H,u'loltic  folds,  and  the  |io>tcrior  surface  of  the 
epi^dottis.  'I'lie  arytenoids  are  almost  as  readily  >wol|cn.  whilr  the 
vocal  cords  and  the  infra^lottic  re^iioii.  with  a  imu'c  closcl\  attached 
mucosa,  are  less  liahle  to  the  disease. 

As  a  rule,  the  aireclion  is  hilateral.  and.  if  iiiu'  •  keil.  -laplivjo- 
c'oeci.  streptococci,  and  other  oroauism-  make  their  appearance  in  the 
indltration-lliiid.  and  the  disease  may  pa>s  thidULih  from  the  -cidii-; 
sla^'o  into  the  purulent.  'I'liese  chan.ii-es  occur  more  rapidly  when  the 
disease  is  unilateral.  The  cmidilioii  in  any  ca.-e  is  one  of  acute  cellu- 
litis. 

Etiology. — Sudden  and  uneipui!  c\po>ure  id'  llie  liodv;  In  cold  is 
the  a|iparent  cause  of  a  majority  <d'  ca>es.  It  i-  liciirrallv  lielie\cd, 
liowever,  to  owe  its  origin  to  micro-oiL;aui>ms:  and  I  hat  the  une(pial 
temperature  to  which  the  p.aticnt  uiitili!  he  c\po>ei|.  i>  onl\  ihe  malih 
vliicli  kindles  the  lire,  the  find  foi'  which  ha>  already  heeii  prepared 
i'or  i<;-nition.  What  would  seem  to  "ive  cidnr  to  this  helief  i>  the  fad 
that,  wliile  exposure  in  one  case  may  produce  >imple  ai-ute  lai\  ii^ilis. 
in  another  similar  exposure  may  residt   in  inteii.-c  n'dcmatou-  di>ease. 

decent  ohservers,  as  Levi  and  Lanieres,  hclicvc  the  o'dema  to  he 
of  infectious  ori.nin.  while  Liaras  helicves  that  it  may  he  even  a  trau- 
matic (cdema,  immediately  dependent  upon  local  vasomotor  disturli- 
ance  the  result  of  voU]. 

(;;:i) 


ii 


E'k 


■672 


inii^E.\i<liii    OF    THE    LAKVNX. 


!■  ( 


It  orcMn>  lunif  fiv(jiu'i)tly  in  iiialcs  tliiiu  fciiialcs.  and  in  early  adult 
lii\'  than  in  Inter  or  earlier  years.  It  i>;  a  rare  disease,  synipathctie 
tedeina  of  tlie  larynx  beinir  nnieli  more  frecjuent  in  occurrence. 

N'oice-strainini,'  has  heeii  an  appa'^ent  cause  in  some  cases,  and 
facial  erysiprlas  has  soniftinn-  heen  rollowcfl  inmiediately  hy  (cdema 
of  the  laryn.v.  which,  in  all  jtrohahility,  \va>  an  e.xtension,  if  not  a 
metastasis,  ol'  the  erysi])elas  itsell'. 

'rrauniatic  causes  will  produce  acute  (udcnia,  as  from  iidialation 
of  hot  steam  or  swallowinj:  of  boiling  water,  etc.  As  a  secondary  atfec- 
tion,  it  may  ari<e  as  a  conii)lication  of  the  various  exanthemata,  though 
the  cases  are  exceedingly  rare. 

Symptomatology. — The  throat  .symptoms  occur  so  ijuickly  and  are 
of  such  distressing  character  that  the  ordinary  premonitory  symptoms 
of  chilliness  and  fever  arc  sometimes  overlooked,  althougli  they  may 
be  jireseiit  in  every  case.  In  the  most  severe  one  that  I  have  ever 
seen  no  premonitory  symptoms  oi  any  kind  were  observed,  save  a  slight 
feeling  of  weariness.  Without  warning,  the  ])atient,  a  strong  young 
man  of  '2'),  was  seized  with  dyspniea,  and  in  six  hours  it  became  so 
severe  that  respiration  liecame  stertorous  and  the  face  cyanotic. 

The  voice  Mion  becomes  lost  in  a  soft  hoarsenes-.  Inspiration  and 
expiration  Itotli  become  lal)orcd.  \{  first  the  face  is  flushed,  and,  as 
diniculty  in  Imathing  increases,  the  purplish  Inu'  of  cyanosis  takes  its 
place. 

'i'hese  symptom^  nuiy  l)ccome  fully  developed  in  from  ten  to 
twenty-four  hours,  or.  as  in  the  case  referred  to,  in  a  shorter  period. 
In  severe  cases  the  result  will  lie  fatal  in  from  one  to  three  days,  with- 
out surgical  relief  of  one  lorm  or  another  is  secured.  In  milder  forms 
of  (rdematous  laryngitis  tlie  course  may  result  in  spontaneous  resolu- 
tion or  the  development  of  abscess  in  some  particular  spot,  with  abate- 
ment of  the  general  ilisease. 

in  the  severer  forms,  if  the  jiatient  does  not  succumb  (|uickly  to 
the  progressive  stenosis,  abscess  may  become  ditfused.  speedily  bringing 
about  a  fatal  issue. 

Diagnosis. — Many  things  will  jiroducc  laryngeal  dyspmea;  and 
to  distinguish  acute  u'denialous  laryngitis  from  all  of  these  a  careful 
laryngoscopie  examination  is  absolutely  nece.s.eary.  Digital  examina- 
tion may  he  of  some  value,  revealing  the  soft  tumefaction  of  the  epi- 
glottis and  aryepiglottic  folds,  but  it  must  he  remembered  that,  with- 
out the  explorer  is  familiar  with  the  touch  of  the  laryngeal  region,  it 
cannot  he  of  much  service.    On  the  other  hand,  in  this  ])rogre.ssive  age 


A(  TTK    (I:I»1;M.\T()IS    I.AKYNCniS. 


373 


it  sliould  1)1'  the  diiiv  ol'  I'very  pliysician  to  I'aiiiiliarizc  hinibrlf  with  all 
tho  methods  usod  in  the  cxploradon  of  the  afrcctod  parts. 

Hy  the  use  of  the  larynjjjoscopo  the  mucous  momhrane  of  the 
larynx  will  he  seen  greatly  distended.  The  epiglottis  will  he  thick- 
ened, partieidarly  upon  its  horder  and  posterior  surface.  The  lateral 
folds  of  the  inner  larynx  will  be  rolled  out  hehind  and  to  the  sides  of 
the  ejjiglottis,  the  three  forming  a  triangidar  chink  in  the  glottic  re- 
gion. 

Although  the  color  is  that  of  iiiereased  redness,  there  is  a  watery 
and  transparent  cast  to  the  tumefaction,  the  extent  of  which  depends 
upon  the  severity  of  the  disease.  When  ])u<  has  commenced  to  form, 
the  spot  of  its  develojimeiit  will  he  marked  liy  increased  swelling  or 
pointing,  as  well  as  the  assumption  ol'  a  lighter  color. 


J'i^t.    IIS.      lin-\MiMir>  liir\  iif.'(nl   kiiivi'f*. 


Prognosis.' — This  is  always  exei'cdingly  grave.  In  some  ca>e«:, 
without  surgical  treatment,  a  rapidly  fatal  result  may  be  expected, 
arising  from  serous  stenosis,  before  the  disease  has  existed  long  enough 
to  give  rise  to  the  development  of  pus.  bidder  cases  may  undergo  reso- 
lution without  j)us-formation,  but  usually  they  end  in  localized  devel- 
opment of  absce,«s,  with  discharge  and  recovery.  The  danger  lies  in 
siifTocation;  hence  the  cases  should  be  watched  with  the  greatest  care. 

Treatment. — Mere  local  applications  of  any  kind  may  be  consid- 
ered as  useless  in  promoting  the  main  object  of  treatment:  the  reduc- 
tion of  swelling.  This  can  be  accomplished,  howcvi'r.  by  free  scarifica- 
tion of  the  inflamed  and  infdtrated  tissues  with  a  curved  laryngeal 
knife,  such  as  Bosworth's  or  Tol)old's,  guided  by  the  laryngeal  mirror 
(Fig.  118).    Free  exudation  of  sero-sanguineous  fluid  follows.    This  can 


i 


<  i\ 


•  I  I  i 


DISK  ASKS    OK    I'lIK    I. A  I!  V  NX. 


I,  K 


lie  iiiilfd  liy  lint  stt'iiin-iiiliiiliit inn.-,  wliicli.  while  proniDtiiiL;'  (lisclinriic, 
liiivr  ii  ;,Miilcriil  I'llVct  ii|Miii  tlif  iiitliiiiH'(|  tissms.  'I'lif  scai'iiitiitiiiii  miiy 
lie  i'f|it';iti'(l  CM  iv  Ifw  li(iiii>  until  tlic  nr;;('nt  >\ni|itnnis  aliiilc.  In  tiic 
fjisc  iilrciidy  iclVrrrd  In.  tliis  |il,in  oT  ircnt  niml  was  rrwanlcd  liv  a  >ii(- 
ccssriil   i>snc. 

I*i\(ir  i('|iniis  a  <-a»('  cuiimI  Ity  cNtfiiial  Ici'diin,!:.  aidcil  liy  hot  I'odl- 
lialli-  and  hot  It'nionatlc  Levi  alxi  rt'iiori-  one  (iircd  liy  apjilyiiiu  six 
leeches  III  the  la  IT  1 1. ilea  I  rcLiinii.  r»(itli  wcic  cyaiictic:  the  stress  was 
laid  nil  the  iiict  that  scariticatinn  was  in  the.-c  case>  nniicccssary. 
'I'iariis  in  I  Sil";  ciind  a  c;i-c  liy  reinii\  iim  a  |iiccc  nl'  the  inlill  rated  inein- 
hranc  hy  |)nncli-r(iice|i-.  thus  pi'dnuitin^'  inr  secretion. 

In  cases  where  snlTnciit  inn  liecnnies  iininineiit.  any  nl'  llie,-e  ineaiis 
caniint  he  relied  nil.  and  1  rachentnmy  will  require  tn  he  dniie.  'There 
is  no  dnnht  that  tin-  n|ieiatinii  i>  |M'(d'eraide  to  iniiiliatinii  in  tlii.-  di>- 
ease.  as  the  laryiiui'al  swelling  is  usually  mi  a  lii.<:iicr  plane  than  the  cap 
nf  the  iiitnhatinii-luhc.  when  placed  within  the  larynx.  ( 'onsetiuen'tly. 
it'  it  were  inserted,  tiie  o'deina  iiiinht  cniitinue  to  produce  stenosis,  not- 
with-landiiii;'  tlu'  presence  of  the  tuhe.  When  ahscessi's  pnint,  no 
matter  where  located,  they  slnuild   lie  pinmptly  npened. 

Siippoi  linu'  measures  diiriiiL;  treatment  are  reiniired;  ami  care 
shniild  always  he  e.xcrcisi'd  against  av<iidalile  changes  nf  tcnnicrat lire. 


i  a 


\i 


1 
1 

1  . 

5 

■      ' 

t 

■       ' 

lliii. 


! 


CIIAl'iKK   I.XIX, 


SlMl'I.K  (KOKMA  OK  TIIK   I.AItVNX. 


I 


SiMi'i.i;  uMlfiiiii  (if  the  larviix.  iiiicoiiiii'clcd  uilli  aiiv  iiilliiiiiinatnrv 
condition  of  thai  orLTaii,  not  iiil'ni|ii('Mliv  mciiis.  It  i>  laii'lv.  Iiov,- 
I'Vcr,  (if  iiKTcIv  liical  iiii,L;in,  Iml  is  a  n^iilt  of  .-cmmc  sy>l('iiiic  disease 
and  is  df  a  sccnndai'v  iialiirc  ll  uceiirs  diiriii;:'  all  |ii'rind.-.  nf  life, 
hut  rarely  in  extreiiu'  aiic     The  inajoiily  (if  (;!-(■>  dcciir  in  iiialo. 

Pathology. —  In  this  disease  theic  is  siiiiply  ell'iisidii  nj  .-criim  into 
the  lodsely-altaehed  sidnmiei/Us  li-siies  df  the  larynx,  the  iiililt  ralidiis 
heiii^'  lar<:t'st  in  the  aryepiuldtt  ie  fdlds  and  the  pdsieridr  >iiiface  df  the 
cpigldttis.  Still,  all  parts  are  liahlc  td  tdiiiefaet  idii,  and  in  sdine  eases 
the  veidrieidar  l)and>  have  heen  the  only  parts  all'ecled.  The  vdeal 
cords  and  suliuldttic  iciiidii  are  not  dften  invdived.  Whenevei'  dh- 
stniction  to  the  Idodd-eiirrent  is  an  element  of  the  ni-ease.  the  slijfhl 
resistance  uliieii  the  larynx  dll'eis  td  inliltratmn  lenders  it  nidic  lialile 
than  other  re^idn.-  to  ininiediale  dropsical  el1'n>i(in. 

Etiology, —  As  It  is  a  secondary  disease,  tin'  cause  must  he  l(idke(l 
for  in  ii'eiieral  alTections  of  the  system  which  have  a  (leterioratinii'  in- 
lluenee  upon  the  vital  powers.  Any  systemic  disea.-e  which  may  pro- 
duce dropsy  in  other  parts  of  the  hody.  other  things  heiui:  e(|nal,  may 
iiive  rise  to  it  here.  I>ri,iiiit"s  disca.M'.  i  uiierculosis.  -iy|ihilis,  and  car- 
cinoma are  amonii'  its  causes.'  ( )l)sli'U(iidn  df  vemiu.-  circulation  fi'om 
the  head,  as  hy  jiressure  fi'om  thoracic  or  amtic  aneurism,  may  al-o  he 
a  cause. 

Symptomatology.- -The  on>ei  oi  the  attack  may  he  -udden.  hut 
usually  it  comes  (Ui  liiadually.  Instead  of  luiarseuos  there  is  very  sddu 
t-omplete  aphonia.  i)yspu(ea  is  the  prominent  symptom.  Inspiration 
lieeonies  exceediuuly  dillicult  dvviu^'  to  the  swdllen  aiyepi,^lottic  folds 
rolling'  in  and  cldsin^-  the  .yldttis.  I''.xpiration.  on  the  other  hand,  is 
not  so  clillieult,  as  the  swollen  liodies  hy  the  elVorl  roll  out  ai:ain.  Still. 
tlie  cords  are  kept  so  wide  apart  hy  the  tumefaction  that  vocalization 
often  becomes  impossihle.  Cyanosis  soon  occui's.  with  all  the  other 
.s_vnip(onis  of  impendin^i'  suil'ocation. 

Diagnosis. — Tliis   is  best   made   hy   the   u>e  of  the   laryn^dx-dpe. 

(.m'i) 


'  W: 


i}H. 


i  i 


r.\i 


-'.i-:..;'.uiawE:^'r 


I 


1  '1 

it 


Ul 


37G 


I)ISEA8i:S    OF   Till-:    I-AUVN.\. 


The  existence  of  larvn^'oal  Htonosis  is  so  selt'-cvidfiit  from  the  syinp- 
toniii  that  the  only  (lilliciilty  is  to  ho  sure  of  the  variety  of  tlio  hiryn- 
geal  disease.  The  aiitoscopc.  too,  particularly  in  yoini;^  sulijt'cts,  shoulil 
serve  nn  excellent  pnr|)ose  in  ,<,Mvin<:f  direct  vision  of  the  infiltrated  tis- 
Bues.  The  resenihhiiiic  to  phle<(M)onoiis  disease;  may  in  some  eases  he 
striking.  Still,  the  swelling  in  o'denia  is  likely  to  he  more  dill'iised 
and  the  color  of  tin;  mucous  mtnihranc  paler,  while  the  presence  of 
systemic  disease  as  the  direct  cause  should  rule  out  the  phlegmonoUH 
or  acute  (edematous  Iaryngiti>.  The  shining,  grayish-white,  trans- 
lucent appearance  of  the  swollen  masses  in  the  larynx  should  distin- 
guisli  the  tedema  from  any  other  lesion. 

Frog;nosis. — As  an  indication  of  serious  organic  disease,  tlie  pres- 
ence of  (cdema  of  the  larynx  is  of  the  greatest  importance,  and  is  usu- 
ally the  prelude  to  speedy  dissolution;  and,  although  the  ]>rimary  dis- 
ease may  he  necessarily  fatal,  the  laryngeal  stenosis  itself,  if  not  re- 
lieved, may  terminate  the  case  in  a  few  hours. 

Treatment. — If  the  (edema  is  severe,  with  threatened  stenosis, 
the  tlr^t  elfort  should  he  to  n^lieve  the  swelling  hy  free  scarification. 
The  room  should  he  warm  and  the  atmosphere  charged  with  moisture 
from  an  evajjorating-kettle.  When  it  arises  from  tuherculosis  or 
malignant  disease  this  treatment  will  often  be  of  service  for  tlie  time 
being,  even  when  constituti(mal  treatment  can  he  of  no  avail.  In 
.syphilis  the  local  scarification  may  reliev(;  the  breathing  while  mer- 
curials and  iodides  are  producing  a  systemic  eifect.  When  general 
anasarca  exists  from  heart  or  kidney  disease  or  cirrhosis  of  the  liver, 
heart-tonics  and  drastic  cathartics  would  seem  to  be  indicated  in  addi- 
tion to  the  surgical  treatment  of  the  larynx,  though  the  relief  at  best 
could  only  be  of  a  very  temporary  character. 

In  malignant  disease  tracheotomy  nuiy  be  retpiireil.  Intubation, 
owing  to  the  chief  efTusion  being  su|)raglottic.  wnuld  in  most  if  not 
all  cases  be  practically  useless. 


i^iliilfi 


(■i!,\i''ii:i{  i.w. 

(  IIHONK    I..M;^M;^l'ls. 

Tills  is  a  clirniiic  iiillaiimiatinii  ol'  ilic  nuirniis  nicmluaiic  ol'  llir 
lar}ii.\.  It  is  usually  sii|ira,i;l()ttic,  Itiit  may  oxti'inl  llirdii^li  tlu'  Vdial 
rords  to  tlic  iiit'ra.i^liitlic  I'c^ioii.  It  is  always  of  a  catari'lial  (■liaiactii'. 
ami  (loos  lint  ipcliidc  all'cft  idiis  of  llic  larynx  aii>in,i;  from  tulicriMilosis. 
syi)]iilis,  or  mali^Miaiit  ilisraso. 

Pathology. — 'riicrc  is  tliickciiiiii;-  of  ihc  mmosii,  with  liyprru'inia. 
tliL'  hlood-vcssols  hoiii^  |K'rmaiit'iitly  dilated;  also  (■cll-prolifciatioii. 
with  increased  socrt'tion.  Winn  the  disease  is  td'  loiii^'  standing  thcp- 
is  increase  of  lymphoid  tissue  as  well  as  of  the  surfacc-cpitliclium  and 
luljidar  irlands.  The  whole  of  the  lininj^  membrane  (d'  the  larynx  may 
he  allVctcd.  or  the  disease  may  he  eonlincd  larirt'ly  to  tlii'  a^ytenoill^. 
interarytenoid  comniissuri'.  and  tlic  ventricular  Iiamls.  Sometimes  the 
vocal  cords  are  involved  in  the  inllammatnry  action.  I'inally,  the  con- 
dition may  extend  dt)wn\vard.  jirodueing  eell-|iroliferation  and  dis- 
charj^e  from  the  infraglottie  rei,non  and  the  trachea  itself.  In  simplt! 
chronic  larynj,fitis  erosions  an;  rarely  jtresent.  When  they  do  occur, 
they  arise  from  the  breaking  of  the  epithelial  coating  from  the  pressure 
of  the  thickened  connective  tissue  beneath,  and  can  only  be  found  in 
cases  of  long  standing. 

Etiologfy. — The  usual  cause  is  some  diseased  condition  of  the  nose 
01  naso-])harynx  producing  nasal  stenosis,  .\nylhing  .lat  will  ))roduce 
chronic  naso-pharyngeal  catarrh  has  a  tendency  to  induce  a  sinular 
condition  in  the  larynx.  Whether  this  arises  from  direct  continuity 
of  the  diseased  mucous  membrane,  or  from  irritation  caused  by  tlie 
presence  of  catarrhal  secretion  in  the  region  of  the  epiglottis  and  aryte- 
noids, opinions  are  divided;  but  where  the  condition  exists,  in  many 
instances,  chronic  hiryngitis  is  the  result.  In  other  individuals,  nasid 
stenosis,  accompanied  by  catarrhal  pharyngitis,  will  directly  induce 
chronic  laryngitis  by  enforcing  the  inspiration  of  nnwarmed,  nnfdtered, 
unsaturated  air,  the  constant  breathing  of  whicli  will  have  an  irritating 
effect  upon  the  laryngeal  mucous  membrane. 

Atrophic  rhinitis  is  also  a  frequent  cause,  particularly  in  cases 

(377) 


ft: 


»1  ■      f  '■■ 


''  '4 


w 

11 

Wi 

fr»^-. 

3T.S 


l>l>-l  ASKS    Ml'    llli:    l.MIVW. 


ti  i 


\\licic  il  liii>  iilit;i(l\  [iKiiliiicd  |iliiii'yii;.'itis  <iccji.  In  llicsi'  in-tiiiicrs 
till'  tiiiliiiiiili  lis  liinc  iiliTiidy  l<ist  the  frmctioii  of  tnuisudnlion,  iind 
till'  iiir  piisx's  over  llicrii  t<»  flic  |jirvii\  iiiiiiKiistciicil  niul  loiiilcil  with 
|iiitn's(('iil  cminifitidiis.  Crusts  iiiid  fmd  liitiiirhid  ^/r/in'v  (d'tcii  iii)|)('di' 
I  lie  I'll!  r;i  lice  In  t  h(    liiivii:^r;d  i  ii\  il  v.  iiiid  cv  civ  I  hiiii;-  diiccllv  hi  Mils  tlu; 

(lr\(|n|i|lir|ll    n|    ;t    (I  I  Idll  ic   Clllll  irhid    ci  Wld  it  inll. 

Ill  iiiiiiiy  in-liiiHts.  |iiirti(Hl;irl\  in  vuict'-iiMTs.  Ihc  tiiisn-pliiirvil- 
^(•!ll  cniidilinii  i>.  not  >nirn  iciil  /"/•  S'  in  illdllic  (he  di»('ilSi',  Init  iiicrrlv 
iicis  iis  il  |n'cdi>|nisiiiL:'  ciiii-r:  iind  iinv  cvccs^ivc  striiin,  I'ithcr  in  <\wi- 
iiii;'  III'  >|i('iikiiiL:.  piirt  il  iihiily  uhcii  lrri|iiciit  ly  if|uiilril,  will  ii'-nll  in 
llic  d('\  clniiiih  nl    III    I  III'  ilix  iisc, 

Miiiiy  spriikri-  uliM  lirciitlir  ((nrccily  when  in  a  piissivc  conilitinii 
entirely  i;:iinic  coirecl  re<|i;riit  inn  while  speiikiiiL:-,  W'lijit  is  eiilled  the 
"reeii\eiy"'  in  iii>|Mriil  inn  is  niiide  hy  llieiii  thrniiirh  the  inniith.  iind 
iml  ihlniiLill  the  iiip-e.  'This  is  u  fiiiill  uhieh.  if  jirnperly  Mlteiided  In. 
enllld.  il>  Il   rule,  he  iivnided.  iltlil.  if  the  ||a-lll   recnscry  \\;|<  ill-i-led   ll|i(i|| 

hy  the  --iicnker.  il  uniijd  nn|  niily  iii-iiic  the  sat  iiriit  imi  lA'  the  rc^pini- 
Inry  iiir.  hiii  wniild  al.-n  make  the  ntleraiiees  ninre  leisurely,  iind  hy 
this  nil  an-  -a\e  I  he  vnicr  I'nr  siiiifi  rs  In  ins|iiie  nii!  ii rally  while  eiirry- 
iiiL'  ell  their  Mieiilioii  i-  iiiiK  II  nmre  di!liiiill.  Il  '-  well  In  renieinher. 
hnwever.  lliiil  iheie  i-  seine  eniii|ieii-;it  inn  fnc  iIh'  hiss  nf  tiirhiiial  .-eere- 
limi  in  these  cii^es  ill  llie  |irnfiise  salivalinii  wliieli  vniee-iisiniT  prndilees. 

I'llniiuated  ii\  iila  iiiid  hypeil  rnpliie  tniisils  iiiiiy  iilsn.  hy  the  pharyii- 
,i:eiil   irrilalinii  they   |irni|iice,  |e;iil  to  chronie  luryiiLTial  disease. 

Miili-  iire  iimre  siihjeel  In  chrnnic  laryii'iitis  than  females,  owiiii^ 
tc  the  iiinrc  fre(|iiiiit  expe-uic.  ;mil.  in  piililic  speakers,  to  iiini'e  ev- 
eessive    li>e   nf   the    Xdiee. 

'I'he  disease  neeiir-  iiinst  frecnieiitlx  diiriii^  I'iirly  iidiilt  iind  iniddlo 
life. 

Symptomatology.  Sjinht  irritatinn  nf  ihe  larynx,  with  tendency 
t(i  repeated  hawkiii;;'.  are  aninii'.,^  the  earliest  syiiiptmns.  Sninetiines 
there  is  ii  sense  nf  dryness,  aeeninpaiiied  hy  spasiiindie  ell'nrts  to  ehiir 
the  throat.  'These  syniptoiiis  iire.  however,  nf  a  minor  idiiiractcr,  and 
arc  marked,  in  ii  meiisiirc,  hy  the  LTadiial  development  of  lioarsonoss. 
This  may  not  he  imtieeil  nuiili  diirin;  ordinary  cnnversation,  Init  in 
sin^nni:-  or  puhlie  speakinu'-  hecomes  iinnoyinir  hotli  to  speaker  and 
hearer.  .\iiy  c.xtra  exertion  of  llu'  voice  in  cither  of  thcst>  ways  may 
produce  hiirninu  JUid  tieklin,<r  sensations  in  the  larynx,  with  tlio  ofTect 
of  prodiiciiii:  a  dry.  spasmodic  coii<rh. 

Tlie  use  of  tlic  voice  by  persons  airoctcd  by  chronic  laryns^itis  is 


m 


(  lllt(»M<      I.AIIN  \(;l  IIS. 


I'm!! 


iniilill 


I'nlldUfil  liV  (lill'i'irllt  |r-||lt«  III  1 1 1  ll'i'I'iMt  |lil-ii|l«.  Ill  Miinc  lni-kill<s« 
will  (|(\('l(i|i  illlu  liniir^rtios.  illlil.  il  till'  voice  ciilltillllc*  t(i  lie  Used, 
illtii  c'llhlilclr  il|illii|iiil.  wllilc.  ill  nllur,-.  r\cll  llnjUM'llt'ss  will  j:ni<lii;illv 
(lisii|)|M'iir  lis  the  >|i('iikiii;.'  m  >iiii:iii;^  nmiiiiiic*.  ninl  the  vnice  lu'i'dinr 
clfiir  lidnrc  (lie  ctid  is  rcnclicil.      In  tlir  lii»l   ilic  hiiv  iiu'cul  i:liiii(liiliir 

-.(•ilTl  it'll  IniiillM  -  (Allilll^tcil.  while  ill  llle  ,-ee(i||il  tile  .-eel'eli  il'V  r<illie|e- 
llil\e  lelililled  llieir  |pnUer.  Ilinl.  lieillL'  >t  i  lllll  lilt  eil  tn  eVtlll  -eeletimi  liV 
tlie  lletiiiii  111'  llie  hllV  II  jeill  llHI-i  le-.  Iia\e  1  111  irieil  I  ei  I  |||e  \ncil|  enlcl- 
iiml    ellilliled    tliejii    [it    |peir(iriil    llieir    illereil>ed    dlltV. 

'I  he  dls(hiir,u(>  I'lniii  the  l;ir\  ii\  iii'e  ii-iiiilly  dT  ii  jfniyi«li  enjnr  mid 

SCllllty.     Witlli'lll     the     illlhllllllliltnl  \     iletinll     eVtelld-     |o    llle     i  II  fnililiiU  ic 

I'CLrinM.  'I'liell  lliev  liecnine  inure  ei)|iiim>  mid  n\'  n  yelliiwi>ll  culnr.  the 
voice    liecoinillli'    more   Cii^ily    I'ntitilied. 

Diagnosis.  -The  'dt-iciie.itcd  ell'mt-  in  chiir  the  ihlont.  with  the 
lioiir^ciie>s  iipdii  ii>iiiL:'  the  voice,  indiciile,  to  -onie  extent,  the  liiltiire 
of  t  lie  di-cii-ie.  'I  hi-  hom-eiie--  i-  li|.:e|y  lo  incie;i-c  n-  ihc  dny  iid\  nil' ■('•;. 
mid  is  ojicii  rclie\(d  hy  ;i  niuhlV  >lcc|i.  St  ill.  1  lieic  me  oi  her  l;iryiii,'ciil 
tioiilile<  which  will  |irodiicc  >iiiiiliir  >yii!  |i|i.ni-.  mid  the  ii-i'  of  the 
liiryiit:{iSCo|ie    i-    rci|llil'cd    to   in.ikc    the  (liii;;lio.-i-  -lire. 

\\\  its  ii-c  the  iiiucoii-  iiiciiilirniie  (d'  ihc  larvnx  will  in'cseiii  the 
ordiiiiiry  ii|i[ieiirmi( c  of  i  hnurc  iiillaiiiniat  ion.  'I'lic  arytenoid-  and 
vcniriiiilar  IhiihIs  will  he  sliuhtly  -wolleii  and  li\  |h  raiiiic.  'I'lic  vocal 
coriU  may  he  somewhat  e(;n;.:c-ted.  hut  there  will  he  no  ;:rcat  swelliiij^' 
or  I  iiiiKd'iicI  ion.  no  iircL;idirit  v  of  moiion.  little  or  no  sin  race-|e-ion ; 
lint  there  may  he  sliiilil  halhinu'  (d'  the  |iart<  in  iniico-|iiis.  Soinetiines 
the  iiiiniile  liiryiiLreiil  \es-el-  may  he  swullcn  and  tortiion-,  part  iciilmly 
(.n  the  posterior  siirlaee  id'  the  epiL:'lotti~;  and,  in  <c\cre  ca-e<.  they 
may  he  distinctly  >een  on  the  \ocal  cord>  .Minnie  uiannlation-  iniiv 
also  appear  on  tin'  vocal  coi'il-  and   int  ralaryicical   walU. 

Prognosis. —  .\s  thi-  disca>e  so  lrc(|iicnt  ly  owes  its  oriLriii  In  le-ions 
ill  the  upper  !iir-pii>-ii,i!es.  the  prot^no-i-  i^  n-nallv  ;:ood,  when  these 
are  removed:  when  the  cause  is  chielly  voice-ahiise,  lei  thi:  cea-e  ami 
the  disease  will  likewi>e.  .\  larue  niiniiicr  id'  ca<es,  howeu'r.  aie  of  a 
very  chronie  (haracler.  when  thi'y  conic  under  the  physician's  iioiiee. 
The  hirynu'ciil  mucosa  is  thickened;  the  -ecret  ioii-,  altlion,i;li  not 
eojiioiis.  have  heeome  hnhitiial:  mid  cure  can  oiilv  he  accoiiip|i,-hcd  hy 
slow  ])rneess.  When  tlio  voice  is  not  an  important  ractm'  in  the  voca- 
tion of  the  iiatient,  the  disoaso  may  remiiiii  stationary  in  many  eases 
without  producing  .«erions  harm.  Still,  the  fact  that  every  frosh  eoM 
niav  result  in  an  acute  or  suliaciite  attack  of  larvn'iitis  in  tho  alrt'adv 


m 


m 


lA 


'^-^"^-'^rajMiSB 


:^so 


DISEASKS    OF    I  III';    I.AUVNX. 


l\! 


i 


«liscas('(l  orgiUi,  would  iiuliciiU'  llial  aiiii'lioratidii  .^lioulii  hi'  aimed  at 
in  all  rases. 

Treatment.-  As  clirdnic  lai'vnuilis  ociurs,  as  a  rule,  in  persons 
ollu'rwise  eiijovin,:^'  i(il)iisl  licallli,  lillle  is  retjuired  in  the  wav  of  svs- 
teniie  treatnieiit.  II'  ihe  liver  is  torpid  a  diolauogue  nuiy  lie  f^iven,  anil 
saline  calliai'tio  niav  l)e  adiniiiistored  wlien  the  pletliora  ol'  tln'  system 
demaiuls  il. 

Ill  ease.-  wlicii'  iiaso-pliarviii;eal  le.-ioiis  have  |iiddurcd  stenosis  or 
catarrhal  disease  in  the  uppei'  air-ti'aii  il  hecomcs  the  iin|)erative  duty 
of  llie  medical  alteiuhnil  to  aim  al  llieii-  removal.  'I'he  only  ipiestioii 
is:  Should  this  he  aecomplished  at  the  lime  when  the  laryiiii'eal  symp- 
toms are  most  nii^ent  or  al  a  later  datcy  The  aii-wcr  to  that  depemls 
upo!i  whether  we  are  callcil  to  ti'eal  Ihe  larynx  in  its  chronic  coiidilioii 
or  ill  one  of  the  acule  cxacerhations  with  w  Inch  il  is  so  oftiMi  altaeke(l. 
In  the  former,  operation  ii|)()n  the  turhinaleds.  se])tum,  nasal  polypi, 
adenoids,  or  tonsils,  when  rcipiired.  >hi)uld  lie  done  at  once.  In  the 
hitter,  wliile  we  may  alleviate  the  steiiotie  symptoms  hy  hivaf^e,  etc., 
it  shoiihl  he  the  aim  to  reduce  the  acute  larynu't'al  condition  hofore 
eonipletin<i  the  naso-pharynjj;eal  treatment. 

I'"i)r  local  treatment  id'  ihe  larynx  I  helieve  lliere  is  no  inslrunient 
so  ^'enerally  useful  as  the  atomizer.  When  properly  eonstrueted  and 
carefully  used,  the  lluid  contained  in  il  can  l)e  ajiplied  thoroughly  to 
tlu'  intrieale  foldin.i^s  of  the  larynx.  To  aeeoniplisli  this  ohjeet  the 
atomizer  sliould  have  a  curved  lip  ai  right  angles  to  the  sliaft  of  the 
instrument.  M'hen  using  it  the  tongue  of  the  patient  should  h(>  iiro- 
iruded  to  its  full  extent,  and,  if  lU'cessary,  held  in  position  hy  the  pa- 
tient grasping  it.  lightly  in  the  fold.-  of  a  doilet.  If  we  desire  the 
a[)plieation  to  reach  the  infraglottic  regiiui.  the  |)alient  should  he  in- 
structed to  inhale  steadily  and  I'orcildy  while  the  spray  is  thrown  in. 
If  the  soluli(Ui  is  intended  to  eonie  in  contact  with  the  entire  upper 
surfaces  of  the  vocal  cords,  or  to  wash  out  the  ventricles  of  Morgagui, 
or  holh  of  these,  the  ]iatient  should  articulate  the  sound  "ah,"  prolong- 
ing out  the  note  while  the  spray  is  thrown  in. 

As  there  is  always  nmrc  or  less  mucous  or  muco-puriileni  secre- 
tion in  the  pharynx  as  well  as  the  larynx,  the  first  solution  used  hy 
the  atomizer  should  he  one  of  the  alkaline  preparations  already  men- 
tioned. AVith  this  the  throat  should  he  thoroughly  washed.  Then, 
if  the  condition  is  temporarily  of  an  acute  character,  a  1-per-cent.  solu- 
tion of  cocaine  may  follow.  This  will  relieve  the  immediate  tender- 
ness and  enahle  an  astringent  spray  to  be  used  without  producing  sore- 


^H  I 


1(1  \n-  aiiiiod  at 

lie,    ill     pi'I'SOTlii 

he  Wily  of  sys- 
\-  lie  j^nvon,  and 
I  of  llic  system 

(■('(1  stenosis  or 
iiporativc  duty 

only  (|iR'sti<)n 
iryn,i;('iil  synip- 
)  that  dt'penils 
nnic  condition 
»rt(Mi  attackcil. 
,  nasal  poly|)i, 

onci'.  In  the 
ly  lavage,  etc., 
ndition   liofoie 

no  instrnnu'iit 
instrurtod  and 
thoroughly  to 
his  oltjoot  till' 
0  shaft  ol'  the 
Oiould  1)0  pro- 
ion  by  the  pa- 
wc  desire  the 
slundd  he  in- 
is  thrown  in. 
'  entire  npper 
:  of  Morgagni, 
"all,"  prolong- 

uriilent  secre- 
ution  used  by 
already  nu'ii- 
ished.  Then, 
per-eonl.  solu- 
ediate  tender- 
rod  ucing  sore- 


ciiiioMc  LAUY.\(ii US.  agj. 

ne.^s.     ir  it  is  siMii)ly  the  ehronic  condition  that  re(iiiires  to  be  treated, 
the  cocaine  may  be  omittetl. 

Of  the  astringents  now  to  bi'  applied,  the  following  may  bo  con- 
sidered in  ortler  of  merit: — 

Argent,  nit.  in  solution,  1   to  ;!  jier  cent. 

/inci  chloridi  in  solution,  '/.  to  I   per  cmt. 

Cupri  sulj)has  in  solution,  J  to  .')  per  eeiii. 

Tannic  acid,  .-.'  to  T)  per  cent.,  with  glycerin,  lo  per  cent.,  in  water. 

•Any  of  these  may  be  thrown  into  the  laryn.x;  and  retained  as  long 
as  possible,  the  patient  returning  daily  to  the  ollice  for  treatment,  or 
at  h)iiger  interval.-,  as  may  seem  advi.sible. 

I'or  the  interim  treatment  to  be  carried  on  at  the  palieiifs  home, 
i  have  always  obtained  better  results  fn.m  I  he  stearoptcue  preparations 
dissolved  in  one  of  ihe  hydrocari^ons  than  from  the  use  of  aiiiieous 
solutions.  Among  the  advantages  of  the  nil  s|>rays  o\cr  the  water  om;s 
are  the  (iiieiie.'-^s  of  atomization,  the  softness  of  the  touch  upon  lii<>  in- 
llamed  tissues,  and  the  consequent  great<-r  ])enctrability  within  iho 
folds  of  the  (irgan.  owing  to  the  absence  of  the  resistance  which  the 
ctiai'>er  sju'ay  produces. 

'J'he  jneparalions  are  much  the  same  as  these  already  mentioned 
in  sjioaking  of  the  treatment  of  jdiaryiigeal  disease,  but  to  save  the 
trouble  of  reference  may  be  spoken  of  again  here.     .Mbolene  is  only 
taken  as  a  good  c.xamjdc  of  the  hydrocarbons. 
Mentliol  in  alboleiie,   1   to  .'>  per  eeiiL. 
'I'hymol  in  alboleiie.  '  '.,  to   I    per  cent. 

1.  IJ  M.ntii,.!     j3r, 

Ol.  ciuydiili \qi 

Alliolfiic    ;}o| 

2.  IJ    'J'llVIlloI         !()(jy 

]\lc!ltll(li    !;J5 

"1-    ■"o>i      iG7 

Alhiilcili'     ;j()i 

1.  H   Mtiuliol    ^  ,,p   ^. 

<  il.  cMryi.iili ^l,^ 

.Mlidli'iic   »j 

Af.  •'■ 

2.  R   Thynidl     „r.  j. 

Moiltliol      rir     V 

(M.     iUllSl     ,1,^ 

Alholi'iie   fi 

M.  ^^" 

34 


n 


1  .'I 


M 


m 


383 


DISEASES   OF   THE    LARYNX. 


l''(>r  liiicr  atomizatioii  to  the  lliri)at,  stron;;or  Holmions  can  be  \\mh\ 
by  means  either  of  the  nebulizer  '/.  tlie  eiumninutor.  'i'lie  Ainoriean 
iH'l)iilizer  is  well  athipled  for  bome-'.se  l)y  the  initient.  As  seen  in  V\'^. 
I  III,  the  lieavier  nil-<,dohiih's  are  thrown  afainsl  tlie  wall  of  the  bottle, 
and  flow  back  into  the  lliiid,  whili'  oidy  the  vaporous  particles  ])ass  out 
of  (he  mouth  of  the  tnb(>  in  a  nii>i.  to  be  iiibah'd  by  tlie  ])atient. 

Tile  iiiulliple  coniininutor  is  a  niorr  cjiiliorate  development  of  tlie 
same  priiK-iplf.  Ily  its  um'  several  vapiu's  cjin  be  coniliined  at  one  time 
for  inhalalion.  if  considered  desirable.  Its  use  is  specially  desifjncd  bir 
tlie  ])liysician's  otiice  (KiJ,^  I'^O). 

Any  of  these  can  be  used  by  the  patient  to  the  throat  with  a  good 
atomizer  or  mluilizcr  two  or  three  times  a  dav.     'To  have  the  licst 


'?! 


t ' 


E 


!..| 


Fif^.  119. — Aiiu'rifiui  iicljuli/.rr. 

efTect  he  should  be  instnicled  to  inhale  deejily  while  upinf^  the  instru- 
ment. In  any  case  the  oil  solution  should  not  be  too  strong  at  first, 
the  ])roportion  of  (li«>  drug  within  the  inenstriiiiin  being  easily  increased 
to  suit  the  susceptibility  of  the  pati(>nt,  and  also  the  kind  of  instrument 
by  which  it  is  to  be  ap[)lied. 

Any  of  these  preparations  have  the  additional  advantages  of  being 
antise|)tie  and  cooling,  as  well  as  astringent. 

Tn  using  nitrate  of  silver  I  prefer  to  apjily  it  with  the  laryngeal 
cotton-holder  after  cocainization,  guiding  it  to  the  part  to  wdiich  it 
is  applied  by  the  use  of  the  throat-mirror,  and  using  care  to  avoid 
abrasion  of  the  surface  by  the  manipulation.  The  use  of  the  laryngeal 
brush  in  these  cases,  while  more  easily  applied,  is  always  more  diffuse 
in  its  application. 


CIIHONir    I,AI(YN'(iITIS. 


383 


Sonic  (iju'iiitors  advise  tho  apjilicatioii  of  astriii^ciits  in  a  dry  form 
by  moans  of  insulllators,  but  tlio  motliod  is  fxcnt'ially  ('oiicodod  not  to 
be  as  otiicacioiis  as  tiic  ono  already  rcfcrrcil  to. 

C'ountcr-irritatioii   over  the   larvnx   niav  also  Ik-  of  ix'iiciit;    also 


Fif^.   I'JO.-    ,Multii)le  comniinutor. 


painting'  the  .-uifacc  with  iodine.  In  some  cases,  wliere  there  is  actual 
doubt  in  dia<inosis,  tlic  administration  of  iodide  of  potassium  may  help 
to  clear  up  the  ditlieulty. 

Care  in  the  use  of  the  voice  is  imperative. 


\n 


'ii 


CllAFTKlJ  l.XXl. 


U 


li 


ATUUl'llIC  LAKYNCilTlS. 

This  is  a  variety  oi'  chrdiiic  larynj^ilis  occasionally  mot  with. 
Lilvc  ordinary  clironic  ]aryngiti^,  it  is  a  seiiucl  or  result  of  disease  of 
the  upper  air-passages.  As  also  chronic  laryngitis  is  usually  the  thick- 
ening of  the  nnu'osa  of  the  larynx,  resulting  indirectly  from  thicken- 
ing or  ]iypertro])liy  of  the  na.-al  and  pharyngeal  tissues,  so.  likewise, 
atroj)hic  laryngitis,  like  pharyngitis  sicca,  is  an  indirect  result,  if  not 
extension,  of  a  similar  disease  from  the  n(i>e  and  naso-pharynx. 

Like  atrophic  ihinitis,  it  is  characterized  by  diminished  secretions 
and  crust-formation  over  the  surfaces  of  the  laryngeal  mucous  mem- 
brane. There  is  also  jiallor  and  shrinkage  cd'  the  normal  tissues  of  the 
parts  a  (reeled. 

I'atliologii'ally  it  is  identical  with  the  disease  of  the  nose  from 
which  it  originated,  and  is  accompanied  by  similar  pathological 
changes.  Loewenherg's  oza'iui  diplococcus  lias  also  been  found  within 
the  crusts  of  the  larynx:  and,  if  the  microbic  origin  of  the  disease  may 
be  granted,  the  like  spori's  will  be  ])resent  wherever  the  disease  may  be 
located. 

Symptomatology. — ('ni,>l-foiiiuuion  is  much  more  severe  during 
the  night-time  than  the  day.  o\'\ng  to  the  cpuetudo  of  the  larynx  dur- 
ing the  hours  of  sleep,  in  the  morning,  particularly,  there  is  a  sense 
of  harshness  in  the  larynx,  with  considerable  didiculty  of  clearing  away 
the  aecinnidated  discharges.  The  masses  expecloraled  come  directly 
from  (he  lai'ynx,  and  are  usually  of  a  greenish  color,  and  possess,  though 
in  a  niiimr  degree,  the  heavy  earthy  odor  characteristic  of  atro])hic 
rhinal  disease.  On  examinatidU  i.f  the  laryngeal  mucosa  the  surfaces 
may  be  found  abraded  or  even  idcerated  and  the  exi)ectoration  may  be 
tinged  with  blood.  It  is  not  unusual  in  atrophic  laiyngitis  for  ulcera- 
tions to  he  extensive,  ]tarticidarly  when  the  disease  has  extended  to 
the  infraglottic  region.  In  this  respect  atro])hic  disease  of  the  larynx 
dilfcrs  materially  from  atrophic  rhinitis,  in  which  tdceration  so  rarely 
occurs;  this  is,  probably,  due  to  the  greater  mobility,  thinner  tissue- 
covering,  and  less  vascularity  of  the  larynx  itself.  I  have  soon  one 
(,)84) 


I 


ATUOI'HIC    LAKYNOITIS. 


385 


t    I 


(1 


(hiring 

■nx  (lur- 

a  sense 

ig  away 


case  in  wiiirii  the  Iruiit  purtions  of  several  of  the  iijijier  rings  of  the 
trachea  were  coinph'tely  dest roved  hy  the  erosion,  only  minute  side- 
fragments  of  tiie  rings  being  lei't.  When  the  vocal  cords  become  in- 
volved in  tlio  disease,  or  when  ernsis  I'orm  over  the  interarytenoid  re- 
gion, the  voice  is  not  only  hoarse,  but  often  a|)hoiiic. 

Diagnosis  shonld  Tiot  be  dil1i<nlt.  Presence  of  atrophic  rhinitis 
and  pharyngitis  sicca  would  lead  to  tln^  impression  that  any  serions 
hiryngcal  trouble  partook  of  tlit;  same  nature.  When.  ad(h'd  to  these, 
are  foul,  oral  breathing,  irritation  of  lower  throat,  sensitive  hyoid, 
cough  with  expectoration  of  gri'i'nish  crusts,  hoar>cness,  and  great  dif- 
ficulty in  clearing  the  laryngeal  cavity,  there  is  little  likelihood  of 
mistaken  diagno.-is.  Kxamination  with  the  laryngoscope  sboidd  re- 
move any  remaining  doubt.  I'liless  there  has  been  thorotiuh  cleans- 
ing of  tlie  larynx,  immediately  before  examination,  the  peculiar  green- 
ish crusts  of  the  disease  will  be  seen  in  posifi(Ui,  above  or  below  the 
glottis,  or  both.  If  th(\v  have  already  been  reuio\ed,  the  llattened  and 
shrunken  and  ))erhaps  ideerated  mucosa  will  l»e  seen,  generally  pallid 
in  color,  and  perha])s  streak(>d  with  blood,  if  haunorrhage  has  taken 
place.  When  the  disease  is  (>xtcnsive,  the  crusts  adhere  to  the  infra- 
glottic  region  more  tenaciously  than  the  snprai;loltie.  owing  to  the 
more  abimdant  supply  of  glandidar  secretions  above  the  vocal  cords. 

Prognosis. — If  taken  early  in  its  history,  cure  may  he  possible; 
but  it  must  be  remembered  that  it  owes  it.s  origin  to  long-standing 
nasal  disease,  which  may  he  incurable  hy  the  time  tliiit  the  laryngeal 
atrophy  has  developed.  In  tlu'se  cas(>s  amelioriition  is  all  that  can  be 
expected.  If,  on  the  other  hand,  the  atrophic  rhinal  condition  can  l)e 
removed  hy  treatment,  the  laryngitis  sicca  shoidd  likewise,  its  a  conse- 
quence, he  arrested.  There  is  another  tiling  to  be  ri'meudiercd:  that 
as  atrophic  rhinitis  under  proper  care  ceases  to  ])resent  seven'  symp- 
toms in  old  age.  the  like  result  miiy  be  expected  in  the  hi-t(jry  of  tlu; 
laryngeal  disease. 

Treatment. — Tlu'  lir<t  and  most  im])(U'tanl  element  in  trcatuu'ut 
is  to  ])lace  tiie  nose  and  naso-])harynx  in  as  healthy  a  comlition  as  pos- 
sible; the  treatment  re(|uii'ed  has  idieady  been  described  when  dealing 
with  these  organs.  This  haviiiu-  been  done  at  each  -iiting  first,  the 
like  procedure  shoidd  at  once  he  applied  to  the  larynx  iis  well. 

For  first  cleansing  nothing  is  better  thiin  a  free  spray  of  DobeU's 
solution,  thrown  forcibly  into  the  larynx  with  the  down  tip  (U'  the 
atomizer.  If  the  crusts  are  dinictdt  to  remove,  the  coarser  vpray  of  a 
curved  laryngeal  syringe?  may  accomplish  their  loosening  more  effect- 


M 

fjijUnHTT^  ' ' 

1 

hm 

I 

? 

»kk\m,-0im»iii\t  »m 


386 


DISEASES    OF    THE    I.AKYW. 


nally.  With  tin-  ai<l  ol'  coiiijjivssi'il  air  and  a  DavidsDii  alomizcr.  tlicre 
should  never  be  any  ilitruulty. 

In  rare  cases  the  use  of  the  hiryngeal  brush  or  eotton-lioltler  may 
be  re(iuired  to  detach  \]\(?  crusts.  1  never  .-aw  a  case,  iiowever,  in  whicli 
tiiis  was  .leeessary. 

As  second  treatment  to  be  applied  each  tinu'  after  the  use  of  the 
cleansing  spray,  the  application  of  the  various  nu'tallic  solutions  are 
recommended.  From  my  own  exi)eriencc.  I  again  ]»refer,  for  their 
mild  protective  inllueiu'c,  the  use  of  the  various  hydrocarbons:  al- 
bolene,  glyeolin,  etc.  With  the  oil  nuiy  be  combined  from  ',  ^  to  1 
]ier  cent,  of  carbolic  acid,  creasote,  or  thymol.  'I'liis  should  be  used 
several  times  a  day  l)y  the  patient,  with  iiistnution-  to  inhale  deeply 
while  using  the  atomizer. 

When  the  case  is  .severe,  the  home  use  of  the  steam-inhaler  con- 
taining a  weak  solution  of  any  of  the  drugs  mentioned  will  have  a 
beneficial  elTect. 


b 


ri 


CIIAITKU  LXXII. 


I'.U'HYDKllMIA  LAUYNGIS. 


This  i^:  a  (lisc'a>o  uliifli  may  ocoiir:  (1)  in  tlu'  n'gion  of  tlu'  vocal 
procoi^K's  of  the  cords;  (•^)  over  the  internal  t;urface  of  the  interarytc- 
iioid  comniissure.  'ilie  first  is  t!;c  verrucous  form  of  ])achydermia; 
the  second  the  ditVusc.  ]ioth  indicate  a  tliickening  of  tissue:  the 
former  circumscrihcd.  the  lattt'r  irregnlarly  hypertrophic. 

Pathology. — Histological  sections  taken  from  the  vocal  jjvocesses 
arc  oval  in  form,  grayish  in  color,  and.  according  to  Damieno.  are  com- 
posed of  jiavement-epithclium,  heing  cliaiigcd  into  epidcrmoidal  layers 
of  ilattencd  cells  without  nucleus,  the  mucous  membrane  at  the  ])oint 
all'eetcd  heing  apparently  transformed  into  tissue  resembling  strati- 
lied  skin.  In  this  variety  the  epithelial  ti.ssues  laicken  at  the  expense 
of  the  submucous  connective  tissue,  which  in  some  cases  is  alnuKst 
absent. 

In  the  interarytenoid  pachydermia  there  seems  to  be  a  local  over- 
growth of  all  the  tissues,  the  connective  tissnc  as  well  as  the  epithelial 
elements  being  alTected.  The  overgrowth  is  usually  fissured  deeply 
from  above  downward. 

AVhile  the  one  class  of  cases  lias  its  origin  in  the  pavement-epithe- 
lium of  the  cords,  the  other  arises  from  the  ciliated  epithelium  of  the 
commissure. 

Etiology. — 'i'he  cause  is  supposed  to  be  the  ])r(sence  of  chronic 
laryngitis,  whether  occurring  upnii  the  cdrds  or  between  the  arytenoids. 
In  singers  and  speakers  overuse  of  the  voice  umlouhtedly  has  an  in- 
lluence  in  the  development:  uaso-phaiyngeal  liypertrophy  is  also  in 
some  cases  a  factor  in  the  ctiolngy  of  the  disease.  One  wtdl-marked 
case  of  interarytenoid  pachydermia,  eciurriiig  in  a  lady-voealist.  T 
traced  to  the  preseiue  of  adenoid  vegetation,  ami  aiu)ther  in  a  gentle- 
man to  throat  catarrh  occasioned  by  the  total  removal' of  the  uvula. 
In  the  former,  ablation  of  tiie  adenoids,  together  with  brushing  the 
])achydermia  with  solution  of  nitrate  of  silver,  resulted  in  complete 
cure  without  return.  In  the  latter  a  change  tn  a  more  ccpiable  climate 
had  a  favorable  result. 

(■■iST) 


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Symptomatology. — When  tlio  nodes  oeeiir  ujmn  the  cords,  gononil 
syiii|itoins  are  very  nlightly  developed.  'I'liore  may  he  weakness  of  tho 
voiee,  however,  attended  l)y  huskiness  or  hoarseness,  owiiiLj  to  tlie  pro- 
jeetion  of  the  hypertropliied  nodules  from  the  margin  of  tho  cords; 
lint  there  is  little,  if  any,  soreness  and  no  coughing  or  expectoration. 

When  the  dilfuse  condition  exists,  there  is  more  secretion,  more 
soreness,  and  laryngeal  distress,  owing  to  tlie  fact  that  the  projecting 
growth  lietween  the  arytenoids  may  prevent  the  complete  closure  of 
the  cords;  the  voice  hecomes  all'ccted,  and  the  patients  c(imi)Iain  of 
aching  and  general  fatigue  of  the  larynx. 

Diagnosis.--  -.\s  pachydermia  of  the  cords  is  largely  an  c])ithelial 
develojnnent,  there  is  some  danger  of  mistaking  it  for  epithelioma; 
and  in  some  instances  it  ha.s  been  asserted  that  the  pachydermia  really 
devclo[)ed  into  cancer.  Damieno  declares  that  these  were  cases  in 
which  the  epithelioma  really  existed  prior  to  or  in  cond)ination  with 
tho  pachydermia,  not  as  a  result.  The  essential  dilTerence  between 
the  two  diseases  exists  in  the  fact  that  in  cancer  tliere  is  true  prolifera- 
tion of  epithelial  cells,  the  cellular  nuclei  being  most  active,  and  the 
epithelial  iirodiicis  penetrating  everywhere  among  the  lymj)]iatics  and 
blood-vessels,  while  in  ]iachydermia  there  is  no  true  proliferation,  but 
liyjiertrophy  of  the  e])ithelium  as  it  takes  place  in  a  corn,  the  cellular 
nuclei  becoming  afro))hied  and  disappearing. 

In  difTuse  pacliydermia  there  is  danger  of  its  l)eing  confounded 
Avitli  laryngeal  tuberculosis  in  the  stage  of  bypertrn]ihy  and  infiltra- 
tion, ]irior  to  ulc(>ration.  The  genei'al  condition  and  absenci^  of  other 
tul)ercular  symptoms,  together  with  microscopical  examination  of  the 
secretions  from  the  larynx,  however,  should  render  the  diagnosis 
tolerably  certain. 

Verriu^ous  pachydermia,  or  ])achydermia  conscripta,  as  it  is  some- 
times called,  is  in  the  form  of  liltle.  hard  nodules  situated  on  or  near 
the  vocal  ])rocesses.  In  rare  instances  they  are  fcuind  at  the  junction 
of  the  anterior  and  middle  tliirds  of  the  (,'ord.  They  are  white  or 
slightly  pink  in  color  and  about  a  ])in's  head  in  size,  in  the  tyjjical 
form  the  noduli'  may  be  single.  During  vocal  ell'ort  it  comes  in  con- 
tact with  the  opposite  cord.  This  at  first  ])roduccs  an  indentation, 
which  by  and  by  gives  way  to  proliferation  and  the  development  of 
another  node.  Tlu'n  the  two,  coming  in  contact,  prevent  proper  clos- 
ing during  vocal  effort. 

Prognosis.  —  Nodes  of  the  vocal  cords  of  speakers  and  singers 
would  frequently  disappear  of  themselves,  if  prolonged  and  complete 


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I'At  1 1 Y  I)i:i(  M I A    I, A  It  V  XUIS. 


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singers 


rest  of  tlie  voice  wtTo  ])riU'tit('(l.  It  is  rare,  however,  tluit  this  can  ho 
accoinplii^hod.  'rrcatmeiit  alone,  without  rest,  is  of  Uttle  avail,  hut 
the  two  comhined  shoiihl  in  all  cases  produce  a  ;^ood  result. 

in  the  ditl"us(!  iiitriarvtenoid  ))acliyderuiia,  lissurcd  thickening' 
liavinif  occurred,  spontaneous  ahsorption   is  oxeeodinirly  rare. 

Treatment, —  In  (h(>  pachydertuia  conseri])ta,  as  said  hel'ore,  some 
cases  will  <i<^i  well  of  themselves  if  tlu'  \(iic(>  is  s^iveii  sullicienl  rest. 
In  mild  cases,  where  Ihe  nodules  ai'c  suivll.  lu'ushinLr  with  "J.")-  to  oO- 
per-cent.  solutions  of  lactic  acid  or  iii-|U'r-(cul.  solutimi  ol'  nitrate  of 
silver  will  result  in  their  removal,  ileforc  the  hrushin.u  a  spray  of  1- 
por-oent.  solution  of  cocaine  would  l)e  reijuircd,  to  still  the  larynx,  so 
as  to  enal)le  the  a|)plication  to  he  conllned  as  much  as  possihle  to  tho 
diseased  ])arts.  Tlu!  treatment  may  he  repeated  at  intervals  of  one  or 
two  days  while  re([uircd. 

In  severe  cases  autluus  diU'cr  greatly  in  tho  treatment  they  advise. 
Professor  Chiari  recommeiuls  tlu*  use  of  electrolysis.  Ileryng,  when 
the  nodes  are  any  size,  advocates  thorough  cocainization  and  then  the 
snipping  olf  of  the  ])rojecting  nodules.  Some  recommend  the  use  of 
a  fine  snare,  and  (Jottstcin  advises  the  use  of  tho  galvanocautery  point. 

In  dilfnse  i)achydermia,  consisting  of  so  much  hypertrophic  tis- 
sue, the  treatnu'ut  may  reipiire  to  he  more  vigorous  to  eil'ecl  a  removal. 
Under  cocaine  a  r)0-per-cent.  solution  of  lactic  acid,  applied  by  means 
of  a  laryngeal  cotton-holder  at  intt'rvals  of  two  or  three  days,  will  in 
some  cases  promoto  ahsorption,  while  in  others  a  1/)-  or  20-per-cent. 
solution  of  nitrate  of  silver  used  in  a  similar  way  will  effect  a  like  re- 
sult. It  usually  takes  weeks  or  months  of  careful  treatment  to  accom- 
plish this. 

In  severe  cases  scraping  the  liy])ertropliic  tissue  with  Krause's 
curette,  as  in  tho  treatment  of  tubercular  iiililtration.  has  been  found 
of  Svrrvice.  This  is  done  after  thorough  cocainization,  and  is  followed 
up  by  ndjbing  the  raw  surface  freely  wiili  tlu'  lactic-acid  solution,  the 
operation  to  be  repeated  if  required. 

PersomUly  I  have  seen  four  cases  of  the  dilfused  variety  {Urilish 
Medical  Journal,  November,  1897).  Two  were  treated  l)y  brushing 
with  solution  of  nitrate  of  silver  and  two  liy  brushing  witli  solution 
of  lactic  a--"d.  All  recovered,  althougli  one  required  treatuu'iit  f<u'  a 
year  and  a  '.<tlf.  Another  had  threatened  return  a«  the  fall  of  the  year 
approached,  and  was  obliged  to  seek  residence  in  a  milder  clime. 

One  case  of  node  of  right  cord,  occurring  in  a  minister,  finally 
disappeared  under  repeated  sprays  of  4-per-cent.  of  menthol  in  al- 


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DISKASKS    OK    TIIK    I.AUVNX. 


bolcnc,  tof^ctlior  willi  comjilcto  ri'st  of  the  voiio  tor  n  miinbor  ot'  wi'oks. 
In  a  second  ciisc,  the  ])atieiit  hein^  a  lectui'cr,  applications  ol'  solution 
of  nitrate  of  silver  after  coca inizat ion.  to^'ctiicr  with  spray  treatment, 
resulted  in  cure 


Si'iua.oTTic  ciiifOMc  i.\i!YN'(irns.  which  Cehrardt  terms  ''chor- 
ditis  inferior  hypertrophica,"  owiny  lo  tiie  fact  that  it  is  attended  witli 
local  suh^dotlic  hypertrophies,  sometimes  occurs,  and  is  likely  to  he 
prtiductive  ol"  a  serious  de<free  of  laryn^^cal  stenosis.  The  '"chronic; 
blennorrluea  of  Stoerck"  likewise  produces  hypertrophies  and  cica- 
trices, but  on  the  vocal  cords,  instead  of  hetween  them.  Klebs  says 
that  histolo-xically  the  eli'iuents  in  hleunorrluea  rrsi'uilih'  those  of  rl)i- 
noscleroma.  It  is  a  (juestion  whether  both  conditions  are  not  of  the 
luiturc  of  pachydermia.    (Lennox  Browne.) 

Treatment  would  consist  of  dilatation,  with  or  without  trache- 
otomy, as  the  indications  of  each  case  miji'ht  call  for. 


I  i; 


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CIIAITKU   I.. Will. 
rSKU l)( )MKM nUANOL S  l.AllY N(i ITIS. 

As  TltiK  or  ]isiHi(l()iiitinlir;uious  croup  is  Iji-licvi'd  by  tlic  iiiiijority 
of  pliysiuiiiDs  to  1)('  liirynucal  dijihtlu'iia.  it  will  not  lie  treated  of  in  tiiis 
voluiiio,  iiiiipimich  as  it  is  fidly  discussed  in  works  upon  general  inedi- 
<ine. 

There  are  eases,  however,  of  traiunalie  pseudomenihraiioiis  laryn- 
;;itis  to  which  a  brief  reference  niighl  be  made.  It  is  reasonable  to 
siijtjiose,  also,  that  if  pseiidonieinbranous  rhinitis  does  occasionally 
occnr,  of  a  purely  idio])athic  character,  with  the  total  absence  of  the 
Klebs-Loedler  bacillus,  so  also  mi^lit  a  similar  disease  occur  in  the 
hirynx  under  favorable  conditions. 

Of  tranmatic  origin.  1  have  had  one  case  which  occurred  in  Au- 
gust, IS!)"^,  thai  of  a  young  lady  aged  v-'i.  (ialvanocautery  operation 
upon  the  tonsils  was  f(dlowed  three  days  later  Ity  iiitralaryngeal  mem- 
branous laryngitis.  In  this  there  was  no  continuation  of  nu'ml)rane 
from  the  tonsillar  operation.  The  epiglottis  was  unalTected  and  the 
membrane  was  fornu'd  upon  the  ventricular  bands  down  to  the  vocal 
cords,  the  latter  bi'ing  sliglitly  involved  in  the  coating.  There  was 
some  laryngeal  stenosis  and  complete  ajihonia.  with  temperature  of 
100°.  Treatment  was  by  stcam-iidialatioii  and  iron  and  glycerin  in- 
ti'rnally.  In  four  or  five  days  the  iucml)rane  had  gradually  <lisa])- 
jiearcd.  There  was  no  recurreiU'c.  The  case  had  no  connection  what- 
ever with  diphtheria,  as  tluTc  were  no  eases  either  before  or  afterward 
in  that  ni'ighborliood.  The  probability  is  that  it  was  a  pure  tibrinous 
deposit  of  staphylococcic  origin. 

At  the  Laryngological  Society  of  Paris,  January.  IS'.U,  Courlade 
reported  a  case  of  ■•recurrent  sultglottie  pseudomembranous  laryngitis"' 
in  a  female  aged  ','.■)  years,  \-\n-  eight  days  the  ])atient  had  sulTocative 
attacks  after  meals  and  at  night.  Two  years  before  she  had  a  similar 
illness  lasting  fifteen  days.  Laryngoscopie  examination  revealed  a 
whitish-gray  plaque  beneath  the  cords.  Antispasmodic  remedies  re- 
lieved the  symptoms,  and  coughing  expelled  four  grayLsh  flakes  the 
size  of  the  little  finger-nail  and  the  tliickness  of  a  ten-cent  piece.    The 

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nplionic  voice  then  liccjiiiic  ikhmiiiI.  ;iiiil  liiiTiiirip>((iiiic  cxniiiiiialinii  re- 
vealed the  iniicdus  iiicinliriiiic  ol'  tlif  sent  i  iciiliir  liiiiiil«.  llic  nrvlciiniils, 
nnd  till'  siil)fjl(ilt  ic  rci^idii  nf  a  (Iccp-rt'il  inlor.  Itiii  willinin  trace  of  v\- 
iiilatidi). 

At  the  l-aiTii,un|(iL;ical  Scciimi  of  the  ! iilcniat ioiial  Mnlical  Cmi- 
^ress  licid  in  .Nfoscow,  in  IMK.  Kosenlierji  rc]iiiitc(l  a  case  of  larvnj,Mtis 
fil)rinosa  in  a  man  aLfetl  (i*.  N'o  infection  enidd  l)e  traced.  The  dis- 
enso  lasted  ei;:lit  days,  and  \\a<  marked  liy  patelies  of  meml)iane  upon 
the  epiLiIoltis  and  inner  walls  ol'  the  larvnv.  the  zones  siirrnnndim:-  the 
alTeeted  sj)ots  hein^;'  >|uite  red  and  inllame<l.  Tlic  miii'oii>  memhrano 
nnd  pldtnirs  were  examined  mi(T(iseo|iieally.  No  di|ilitheria  haeilli 
wej'e  found,  liiit  staphylneocei  and  streptococci  were,  ami  the  false 
niend)rane  was  lihrinous. 

Middlenias  Hunt  also  rejiorts  a  ease  (d'  reenrreni  mendnaiions 
larvn^dtis  which  had  existed  olV  and  on,  in  a  nnddle-a^red  lady,  for  1!> 
years.  The  ni(>nd)rane  would  form,  accompanied  by  acute  sore  throat. 
and  would  last  for  a  week  or  two.  and  then  disappear  for  a  similar 
period,  to  he  followed  hy  another  attack.  It  was  always  located  to  the 
left  side.  Sta])hyloeocci  and  stn^ptocneei  woidd  he  f(nind,  hut  m> 
Klehs-Loefller  haeilli. 


CIIAI'TKR  LXXIV. 


I,AUVN(ii:AI,  PKKUlinNDKlTIS. 

Tills  iri  a  rare  discaf^c,  occurring  soiiu'limcs  as  a  rcsiili  of  t^ypliilis, 
tuberculosis,  or  tancor  of  the  larynx.  Jii  a  iVw  iiistancop,  as  in  the  cases 
of  Xewuian  and  .lurasz,  il  di'veUjps  an  an  acute  idiopathic  airoction; 
i.ccasionaily  it  occurs  as  a  sciiuciu:c  lo  one  ol'  tlu'  cxanthcuuita.  It 
comes  on  very  siuhlenly,  is  al  tended  hy  the  grave.-l  syinpioins,  and  is 
sometimes  so  obscure  in  its  uiaiiil'estations  that  a  pusiiive  diagnosis 
iieconies  exceedingly  dinicult. 

Pathology. — There  is  at  iirsi  increased  vascularity  in  the  jji-ri- 
chondriuiu  of  the  cartiln'^e.  'i'iiis  gradually  exiends  lo  tlu;  cartilage 
itself,  with  increased  cell-i'orinati(m  and  swi'lliug  This  nmy  be  fol- 
lowed by  formation  of  ])us  Ijcnratli  ttie  pcricluuulriuin.  separating  it 
from  the  choiulrium  and  involving  the  latter  in  nccmsis.  or,  l>y  slower 
])roccss,  cell-organization  and  hypertrophy  may  take  place. 

Of  all  the  cartilages  the  cricoid  is  most  freiiueiitly  all'ected  in  the 
acute  idio])alhic  disease,  and,  as  a  rule,  the  inllammatioii  confines  itself 
to  the  cartilage  primarily  involved.  In  tuberculous  cases  the  aryte- 
noids are  the  most  freiiucnt  scat,  and  in  these  the  inllammatory  action 
usually  extends  also  to  the  cricoid.  As  regards  frequency  of  develop- 
ment, ]}osworth,  out  of  ',V,i  cases  collateil,  found  that  ^3  involved  the 
cricoid,  3  the  thyroid,  -1  the  arytenoid,  1  the  cricoid  and  thyroid,  and 
in  2  cases  all  the  cartilages  were  involved.  Luning,  out  of  55  cases 
collated,  found  disease  of  the  cricoid  in  22,  of  the  cricoid  and  arytenoid 
in  14,  of  arytenoid  in  9,  of  thyroid  and  cricoid  in  5,  of  thyroid,  cricoid, 
and  arytenoid  in  3,  and  of  thyroid  in  2. 

Etiology. — As  a  single  causc^ perhaps  ex|)osiire  to  cold  may  claim 
the  gi'catcst  numl)er.  It  is  likely,  however,  that  some  acquired  or  in- 
herited weakness  of  constitution  has  in  each  case  been  a  predisposing 
factor.  Typhoid  fever,  scarlatina,  diphtheria,  tuberculosis,  syphilis, 
etc.,  are  also  exciting  causes,  as  also  is  Iranmatism.  The  majority  of 
cases  occur  in  males,  and  the  period  is  during  adult  life. 

Symptomatology. — In  very  acute  cases  the  disease  is  likely  to  be 
ushered  in  by  a  well-marked  chill  and  localized  pain.  As  a  rule,  how- 
ever, as  there  has  been  some  previous  indisposition,  the  chilliness  may 
be  mild  or  even  absent.    Fever  follows  of  two  or  three  degrees,  with 

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DISEASES    t»l'    illi;    I.AliV.W. 


]tiiiii  in  till.'  hones  iind  ^Tncriil  (listrc-«  of  the  syi^toni.  arisiiii,'  from  ilic 
approach inif  (lilliculty  of  respiration  and  di'u'hitition. 

When  the  cricoid  is  aflVcted.  tlic  swclliii.LT  on  tlic  inner  sui  face  of 
the  cartihiii'e  seriously  interferes  willi  hrealhiuL'.  l»otli  inspiration  and 
expiration  heinfjj  prohmired  and  dillicnll.  'I'hc  tnniefaetion  and  sore- 
ness will  also  ii\tor!'ere  witli  de^lntilion.  When  the  arytenoids  are  in- 
volved, the  (losing  of  tlie  glottis  cannot  he  conipleted,  and  hreathini;- 
may  he  easier  than  with  cricoid  steiio-is,  while  ()dynj)!ia;4ia  and  dys- 
phajria  will  l)olh  lie  more  severe.  IN  richomhitis  of  tlie  thyroid  carti- 
lage is  nsually  on  the  inner  surface  and  unilateral.  In  this  case  the 
voice,  altiu)uuh  hoarse,  may  not  he  entirely  lost;  when  1)ilatoral  it 
nsually  is.  The  epiglottis  l)eing  comjiosed  of  fihrocaililagc  instead  of 
simple  cartilage,  jiosse^^ses  nKU'c  power  of  resistance,  and  is  rarely,  if 
over,  attacked  hy  idio]iathic  disease. 

In  acute  cases  (he  syni])toms  may  reach  tlieir  utmost  s(>verity  in 
a  very  few  days,  while  in  chronic  ones  they  may  exist  a  muidi  louLicr 
time  without  ])rodiieing  severe  stenosis. 

Diagnosis. — 'J'ho  sudilenncss  of  the  attack,  accompanied  hy  steno- 
sis and  fever,  with  the  ahsenec  of  diplitheritie  symptoms,  may  give; 
some  idea  of  the  nature  of  the  disease.  Still,  it  may  not  he  easy  to 
arrive  at  a  correct  conclusion,  even  with  the  aid  of  the  laryngoscope. 
With  the  development  of  ahscess,  there  is  more  or  less  ledema;  and, 
although  the  attending  fever  may  distinguish  it  from  simple  (cdema, 
yet  the  laryngeal  images  of  the  two  are  soint'tiines  so  much  alike  that 
doubt  may  be  occasioned.  When  the  swelling  is  not  great  enough  to 
obliterate  the  view  of  the  infraglottie  region,  the  unilateral  charact(>r 
of  the  perichondritis,  with  the  swelling  on  the  one  side  and  the  couse- 
<[uent  visible  distortion  of  the  laryn\,  will  aid  in  diagnosis.  This  is 
particularly  the  case  with  the  supraglottic  cartilages,  but  with  the 
cricoid,  the  disease  l)eing  almost  centrally  situated  and  the  swelling 
widely  diffused,  it  is  often  imjiossilde  for  the  laryngosco])e  to  reveal 
anything  but  general  ledcjua  of  the  parts. 

'J'his  was  particularly  the  case  in  a  man,  aged  od,  wliont  1  saw 
in  consultation  sotue  years  ago.  Acute  laryngitis  of  some  sort,  ac- 
companied by  dillicult  respiration,  came  on  suddenly.  In  forty-eight 
hours  from  the  sup|)osed  commencement  (d'  the  attack  I  was  sum- 
moned. The  man  was  amemic;  breathing  was  stertorous,  inspiration 
was  more  diflicult  than  ex])iration.  Tie  had  no  pains  and  could  walk 
about  with  ease;  temperature.  10(1°.  By  the  laryngoscope  the  larynx- 
was  found   to  be  (edematous.      Pioth  arytenoids  and   epiglottis  wcr<> 


ac- 
h'i.iiiit. 
suni- 
iitioii 
walk 
iryiix 
wore 


I.AUYNtiKAI,    I'KIUCnONDIUTIS. 


3!ta 


8\vull('ii.  \  (H  ill  (iikIs  vuuh\  iidt  lie  -ffii.  r>y  ii>iii,i;  s|iray  of  cofaiiu; 
and  menthol  in  solution  lip'atliini;  hccanic  >li,iiiitly  easier.  It  did  not 
seem  advisalile  to  [tert'onn  ti'aclii'oioniy  iinine(liately.  iiarticidarly  as 
the  patient  \vanle(l  any  opei'atioii  jmstponi'd  a-  Idii.ir  as  jxissihlo.  1  did 
not  see  liini  apiin  alive,  as  the  lollowinir  chiy  he  was  thoULdit  to  l)e 
easier.  The  .-ueeeedin^-  night  the  steitor  heeanie  more  severe.  The 
doctor  was  snninioue(l,  A\'hen  he  arri\e(l  half  an  Imur  later  the  pa- 
tient was  dead. 

.■\t  the  [)ost-inortein  we  discovered  an  i'\leii~i\e  pcriehondrial  all- 
seeds. exteniliiiL;  more  tlian  hall'-way  round  the  inner  surface  of  the 
i-ricoid.  .V  portion  was  to  the  riui'hl  siih',  hut.  after  extending:  over  tlie 
anterior  surfac(>  of  the  iio-lcrioi'  half  of  ihe  riui;'.  it  laruelv  tilled  in  the 


Kij;.  I'il.  .Mix-OS  (if  i-iiitiiil.  Liirviix  oiitiicd  fidiii  tK'hind.  'I'lic  (larl< 
s[i(it  ticlow  tli(>  cciitic  Miiil  to  tilt'  left  side  iiuliciitis  flic  lai},'('i'  opeiiiiig;  the 
lij;ti(cr  >|i<it   til  llic  liu'lit.  the  siiiallcr  (inc. 

left  side,  the  caitilag'e  itself  heini:  denuded  and  tlisortfanized.  The 
other  cartilages  were  in  no  way  alVecied  ( l'"ig.  l^M). 

I  was  informed  hy  a  meinher  of  tlu'  family  that  a  hrotlier  of  llie 
deceased  died  <d'  the  saiiie  troiihle  se\eral  years  previously. 

Prognosis. -- The  immediate  danger  is  from  laryngeal  stenosis. 
Tn  chronic  ease,'~  this  comes  on  so  gradually  that  there  is  lime  for  con- 
sideration hefore  operation  is  re(|uired.  .\s  disease  of  the  ciicoid  |)ro- 
d-u;es  the  most  extensive  swelling,  it  is  usually  attended  hy  the  most 
danger.  When  several  cartilages  are  inv(dved.  the  prognosis  is  most 
nnfavoral)lc.  In  neaily  all  ca.ses.  however,  life  might  lie  prolonged  if 
traclieotomy  were  peiformed  comparatively  early  in  the  disoa.se.  The 
presence  of  the  purulent  sac  within  the  larynx  would  jH'cclude  tlie 
a(lvisn1)ilitv  of  intnhation. 


n 


11 


it 


:     !. 


HI 


^1 

1 

J    ■ 

1 

39C 


D1SKASK6    OF   TUK    LAUVNX. 


\h    i 


ii^  m 


'  n 


Treatment. — Wlu'ii  the  progivs.s  of  iho  di&oasc  is  ^luw  onougli  to 
iillow  of  systemic  troatmeiit,  tliis  may  he  tried  in  the  way  of  antiphlo- 
gistic and  diuretic  measures.  In  eases  in  wliieh  the  (vdema  is  not  too 
great  to  permit  of  laryngeal  ohservalion,  the  point  of  protrusion  may 
he  freely  opened  hy  the  laryngeal  lancet,  after  which  inlialations  of 
steam  will  favor  a  free  diseliarge.  Wlien  i)ointing  externally,  it  should 
he  opened  early  and  discharge  encouraged. 

Jn  cases  of  severe  stenosis,  however,  whether  from  the  cedema  of 
the  parts  or  the  pressure  of  the  })us-sai'.  trat'heotomy  is  always  advis- 
ahle.  Artificial  respiration  once  estahlished,  ell'orts  can  be  made  to 
more  llioroughly  treat  the  jieriehontirial  inllammation.  and  when  re- 
quired it  is  possible  that  the  diseased  cartilage  itself  niight  be  removed, 
in  the  absence  of  systemic  disease. 

Supporting  treafment,  when  there  i<  any  prospect  of  prolonging 
life,  is  always  called  for.  and,  owing  to  dilliculty  in  deglutition,  recourse 
may  be  had  to  enemata. 

'J'he  case  1  referred  to  is  one  in  which  1  lielieve  tracheotomy  should 
have  been  done  at  the  time  of  my  firsl  and  only  visit.  There  is  little 
doubt  but  tliat  it  would  have  prolonued  the  patient's  life;  and  1  have 
often  regrt'tled  since  that  1  did  not  insist  at  the  time  upon  giving  him 
the  required  relief. 

AFFKOriON.S  OF  TllK  ClUCOA  K  V  PHNOID   AkTICI'I.A  I'lON  . 


'1^ 


l)e  la  Sota  was  the  first  to  describi!  luinuiry  inflammation  of  this 
Joint  due  to  exposure  to  cold,  and  Debrousses,  in  J 8(11,  was  the  first  to 
express  tlie  opinion  thai  such  a  trouble  might  l)e  rheumatic  in  char- 
acter. 

AVhen  it  is  remembered  that  the  cricoarytenoid  articulation  is  -up- 
plied,  like  the  other  joints  of  the  body,  with  capside  and  ligaments  and 
a  true  synovial  niem])rane,  besides  possessing  slight  rotatory  and  lateral 
iiiovcnu'nts,  it  is  but  natural  to  believe  that  it  nuiy  be  subject  to  the 
tisual  run  of  joint  diseases.  The  investigations  of  more  recent  observ- 
I'rs  have  borne  out  this  idea. 

In  1880  Archambault  wrote  that  acute  laryngeal  manifestations 
of  rheumatism  were  more  common  than  was  generally  supposed,  and 
that  one  of  its  manifestations  was  in  the  arficulati(uis. 

In  1887  George  W.  Major,  of  Mojitreal,  drew  attention  to  several 
affections  by  which  the  cricoarytenoid  articulation  was  sometimes  in- 
vaded.   These  were  sprain,  dislocation,  direct  local  injury,  acute  ,(R- 


kliS'll  I 


AFFECTIONS   OF   TUB   CRICOARYTENOID   ARTICULATION. 


397 


llamiiiiilioii,  and  ankylosis.  Of  these,  he  gave  instances,  ankylosis  of 
the  joint  being  the  most  common.  The  chief  causes  meniioned  are 
jierichondritis,  rheumatism,  gout,  the  exantliems,  and  catarrhal  aircc- 
tions;   the  chief  of  these  is  rheumatic  intlainiuation  of  tlu'  joint. 

The  leading  symptom  is  embarrassed  breathing.  The  voice  is  not 
much  interfered  witii  and  swallowing,  as  a  rule,  is  not  dilVicult.  ¥.n- 
largement  of  the  joint  may  be  present,  but  there  may  be,  in  advanced 
cases,  atrophy  instead.  Other  symptoms  aie  external  tenderness  and 
friction-sounds  on  manipulation. 

Six  years  later,  in  an  elaborate  and  valuable  paper,  bearing  the 
title  of  "Arthritis  DL'formans  of  the  Larynx,''  Casselberry  gave  the  his- 
tory of  an  exceedingly  interesting  case.  'J'his  occurred  in  a  lady  aged 
.58.  She  was  a  subject  of  general  arthritis  deforninns,  the  joints  of 
both  sides  of  the  body  being  all'ccted  alike.  The  hands  and  wrists 
were  distorted,  the  fingers  and  thumbs  dislocated,  and  the  feet  and 
ankles  siniilarlv  aU'ected,  though  in  a  minor  degree. 

The  cricoarytenoid  joints  were  also  ankylosed  on  each  side  alike. 
The  vocal  processes  of  Die  arytenoids  were  similarly  alfected,  the  swell- 
ing extending  to  the  cords  themselves.  The  poslt'rior  I'uds  of  the  cords 
were  both  thickened,  ])rojecting  downward  and  upward  and  beyond  the 
natural  line  of  the  rima  glottidis.  The  abductor  muscles  were  so  lim- 
ited in  their  action  as  to  prevent  material  opening  of  the  glottis. 

The  history  of  this  case  ))roved  thai  it  was  in  no  sense  one  of 
paralysis,  and,  strange  to  say,  neither  did  it  seem  to  be  one  of  gout  or 
rheumatism.  This  lady  had  never  sulfered  from  ])ain  in  any  of  the 
•uints  during  the  develoi)ment  of  the  disease,  and,  what  is  more,  medi- 
c.  .OS  administered  for  tlie  relief  of  gout  or  rheumati>m  had  not  had 
: 'ic  slightest  ed'eet  in  arrt'sting  the  progressive  deformity,  ^\'hile  un- 
der Casselberry "s  care  sprays  and  inhalents  ail'ordi'd  temporary  relief. 

Xewcomb  has  also  written  upoji  the  '"laryngeal  manifestations  of 
rheum  iIimh,"  dwelling  particularly  u])on  its  develojimenl  in  the  crico- 
arytenoid joint,  the  symptoms  being  similar  to  those  described  by 
Major,  lie  s])eaks  also  of  the  dcper  congi'stion  wliieli  (ucurs  along 
the  line  of  eoiitaet  between  ihe  ai'tieular  surfaces  of  the  cartilages 
alfected. 

Concerning  treatment  of  the  rheumatoid  condition,  nothing  has 
yet  licen  found  to  take  the  place  of  the  salicylates.  Salol,  or  salicylate 
of  phenol,  is  a  good  addition  to  the  group.  IngaLs  has  found  much 
relief  in  these  cases  from  a  combination  of  salol  and  extract  of  Phyto- 
lacca in  V^-gramme  doses  of  each.    Guaiac  is  also  sometimes  useful.. 


25 


^i 


'a,  1 


I 

I  I 


.;    \ 


I     : 


^  -iieemsaaaiaitstasis^sasssi 


i: 


ClIAPTEK  LXXV. 


tubkik;ui.osis  of  tiik  i.arynx. 


ii 


M 


This  (lii^case  is  said  to  occur  in  from  10  lo  20  per  cent,  of  all'  cases 
of  piilnionary  tnbercolnsis.  in  a  large  majority  of  cases  it  is  secondary 
to  that  alfeetion,  alti,  i  '  '  i  a  certain  proportion  of  cases  it  exists  as 
a  primary  disease.     lio  a  tal^es  tlie  ground  that  the  tubercular 

process  has  added  virulence  as  it  occuis  nearer  the  outer  world,  while 
at  the  same  time  it  occurs  with  less  fretpiency,  the  ratio  l)eing  inverted. 
That  is  to  say,  that,  while  pharyngeal  tuberculosis  is  the  rarest  of  tuber- 
cular manifestations,  it  is  the  most  ra])idly  fatal.  And  laryngeal  tuber- 
culosis, occupying  a  medium  position  between  the  pharyn.x  and  lungs, 
also  occupies  a  median  position,  both  with  regard  to  severity  and  fre- 
(piency  of  the  disease.  Hence  it  is  less  frequent,  but  more  rapidly 
fatal,  than  simple  pulmonary  tuberculosis. 

Pathology. — 'J'he  morbid  process  of  tuberculosis  is  essentially  the 
same,  whatever  part  of  the  body  it  occurs  in,  being  based  upon  the 
presence  of  the  tubercle  bacilli  in  the  affected  tissue.  In  the  large  ma- 
jority of  eases  the  fornuition  of  tubercle  witliin  the  larynx  is  secondary 
to  prinuiry  pulmonary  disease,  in  rare  instances  it  may  arise  in  the 
larynx  dc  iioro. 

In  the  earliest  stages  of  laryngeal  tuberculosis  there  is  infdtration 
of  the  mucous  membrane  of  the  parts  affected,  with  multiplication  of 
round  embryonic  cells,  lymphocytes,  and  leucocytes.  In  the  central 
portion  of  the  periphery  these  small  cells  may  aggregate  more  densely, 
resulting  in  necrosis  and  ulceration  of  fh(>  part,  with  de]iosit  of  cheesy 
matter  in  the  submucous  layer.  Quite  frequently,  although  the  tuber- 
cle bacillus  is  considcreil  the  primary  agent,  it  may  be  dilTicult  to  dis- 
cover it  microscopically.  I'sually  the  nodular  or  tubercular  deposit  is 
at  first  subepithelial,  gradually  working  toward  the  surface,  and  re- 
sulting in  ulceration.  In  lu'arly  all  eases  the  disease  is  progressive,  the 
spots  of  disintegration  mulfiplying  as  the  tuberculosis  extends. 

The  amount  of  infiltration  varies  in  different  cases.     In  some  it 
is  very  superficial,  and,  according  to  Clifford  lieale,  this  class  of  cases 
is  very  much  more  amenable  to  treatment  than  when  the  disease  ex- 
tends to  the  submucous  layer. 
(398) 


TUIiEUCULOSlS. 


399 


When  or  recent  dovolopnient,  the  iihers  arc  tjluiUow  and  super- 
ficial, with  jagged  edges,  tlie  base  being  gray  and  smootli.  On  tlie 
other  hand,  old  ulcers  are  irregular,  studded  with  ludlows  and  small 
cavities,  around  which  the  tissues  are  sclerosed. 

"J'he  most  frequent  site  is  said  to  be  the  arytenoid  comnii.-sure, 
next  the  arytenoids,  ventricular  bands  and  cords,  and  perhajjs  last  the 
epiglottis,  although  authorities  dill'er  as  to  the  l're(|uen('y  with  wliicii 
the  last  mentioned  is  affected. 

In  some  eases,  although  the  arytenoids,  commissure,  and  ven- 
tricular bands  may  be  involved,  the  cartilages  being  ulcerated  and 
eroded,  the  vocal  cords  may  remain  intact  even  to  the  last.  In  other 
eases  they  are  the  chief  seat  of  the  disease,  one  or  both  being  thick- 
ened and  jagged  for  the  whole  length  of  the  border.  When  the  ])eri- 
chondrium  is  seriously  invaded  by  necrosis,  extensive  (cdema  of  the 
.submucous  tissues  is  likely  to  ensue. 

Etiology. — Tuberculosis  of  the  larynx  is  usually  a  hual  inani Testa- 
tion of  a  systemic  disease.  It  is  rarely  primary  in  origin,  but  dependent 
upon  a  pulmonary  tuberculosis  already  present.  Granting,  however, 
a  constitutional  weakness,  abrasion  or  relaxation  of  the  laryngeal 
mucosa  may,  in  some  cases,  ])erniit  the  invasion  of  the  liiicillus  and 
the  primary  development  of  the  disease  within  the  larynx. 

Hereditary  tendency  has  an  undoui)ted  influence  in  tbc  etiology 
of  this  disease.  Catarrhal  pharyngitis  and  laryngitis,  as  well  as  con- 
tinued exposure  to  cold  and  wet,  may  also  be  classed  as  predisposing 
causes. 

As  tidjerculosis  usually  occurs  in  the  lungs  first,  autoinfeetii)n  is 
believed  by  many  to  be  the  chief  cause  of  its  occurrence  in  the  larynx, 
any  abrasion  of  the  mucous  membrane  of  that  organ  givinij:  ready  lodi,''- 
ment  to  the  tul)ercle  bacilli,  on  tluir  way  outwaid  in  the  act  of  cough- 
ing; or  invasion  may  occur  through  the  medium  of  the  lympliatic  ves- 
sels with  which  the  larynx  is  so  freely  endowed. 

Tubercidar  laryngitis  occurs  more  freiiuently  in  males  than 
females.  It  is  also  a  disease  of  adult  life,  by  far  the  lai'gest  iuind)er 
of  cases  occurring  between  the  ages  of  twi'iily  and  foiiy  years. 

The  jiereenlage  of  eases  of  judmoiuiry  tubfrcidosis  whicli  are  fol- 
lowed by  tuberculosis  of  the  larynx  is  variously  estimated  by  different 
writers,  the  figures  being  between  10  and  .")0  ]wt  cent.  Terliaps  the 
medium  of  20  will  be  the  nearest  to  the  trtdh. 

Symptomatology.- — Impairment  or  softening  of  the  voice  is  one  of 
the  earliest  symj)toms.     This  is  to  be  distinguished  from  the  harsh 


if 

, 

• 

':{        ! 

■i.'        ? 

1  ;     i 

a 


5 

i^ 


\  i 


M' 


,1 


ii' 


-J 


400 


DISKASKS    OF   TUK    LAUVNX. 


\ii 


:i'l 


.'.! 


if: 


voice,  with  lowered  pitch,  rcsiiltiiif^  from  simple  chronic  laryni^itis. 
In  this  (lisense  the  muscles  of  the  larynx  are  weakened  and  relaxed, 
while  the  infiltration,  which  so  freiiuently  occurs  at  the  arytenoid  com- 
missure, ])revents  the  proper  vocal  adjustment  of  the  cords,  with  con- 
seqnent  loss  of  voice  even  to  the  extent  of  a])honia,  as  the  disease 
progresses. 

Wlien  the  disease  is  unilateral  and  situated  entirely  ahove  the 
vocal  cords,  or  located  in  the  epiglottis  to  the  exclusion  of  other  points, 
impairment  of  voice  may  not  he  present. 

Pain  is  a  frequent  symptom,  especially  during  deglutition.  When 
the  upper  portions  of  the  larynx,  such  as  the  arytenoids  and  epiglottis 
are  affected,  the  pain  is  usually  more  acute,  and  after  ulceration  has 
commenced  may  be  very  severe. 

Cough  is  pro])ably  present  in  all  cases,  the  pulmonary  cough  being 
notably  increased  by  the  laryngeal  irritation. 

There  is  also,  particularly  when  oedema  exists,  a  feeding  of  fullness 
in  the  region  of  the  larynx,  which  is  very  distressing  to  the  patient. 

The  expectoration  in  the  early  stage  as  coming  from  the  larynx 
is  limited.  As  the  disease  advances  the  secretion  becomes  more  abun- 
dant, and  consists  of  gray,  ropy  mucus,  as  distinguished  from  the  heavy, 
muco-purulent  matter,  the  product  of  pulmonary  disease. 

The  ordinary  systemic  symptoms  of  tuberculosis  will  more  rapidly 
assume  an  aggravated  form  upon  the  addition  of  the  laryngeal  disease. 
Emaciation  comes  on  more  quickly,  mental  anxiety  is  greater,  and  the 
pain  sustained  liy  the  patient  is  more  severe  than  when  jjulmonary 
tuberculosis  exists  alone. 

Diagnosis. — When  the  examination  of  the  lungs  indicates  tul)er- 
culosi>,  ]iarti('ularly  if  microscopical  examination  of  the  sputum  dis- 
covers: the  presence  of  tuberch}  bacilli,  any  decided  softening  of  the 
voice,  together  with  laryngeal  pain,  will  render  the  diagnosis  of  laryn- 
geal tuberculosis  almost  certain.  Laryngoscopic  examination,  how- 
ever, will  always  be  necessary  to  make  positive  the  location  and  extent 
of  the  disease.  In  cases,  too.  where  the  lungs  are  affected  to  only  a 
limited  extent  or  not  at  all,  the  only  certain  way  of  arriving  at  the 
truth  may  be  by  the  use  of  the  laryngoscope. 

In  this  disease  the  mucous  mendirane  of  the  larynx  and  even  the 
pharynx  will  have  lost  to  a  large  extent  its  accustomed  pink  color  and 
be  more  pallid  in  appearance.  This  will  distinguish  the  tuberculosis 
from  the  hypera;mia  of  syphilitic  and  malignant  disease. 

'I'his  pallor,  with  swelling  or  infiltration,  is  the  earliest  local  sign 


!     !    » 


TUBERCULOSIS. 


401 


revcnled  by  the  laryngoscope.  I'lio  swelling  is  confined  to  the  s])ot 
involved  in  the  disease,  the  pallor  being  diirused  over  tlic  surrounding 
tissues.  The  infiltration  is  at  first  unilah.'ral,  but  may  soon  extend  to 
the  opposite  side,  assuming,  in  the  case  of  the  arytenoids,  the  elub- 
shape,  and,  in  the  epiglotlis,  the  turban  form. 

Prior  to  ulceration  the  membrane  of  the  swollen  tissues  is  of  a 
dull-gray-yellowish  tinge,  smooth  and  moist,  Itut  without  the  semi- 
transparent  appearance  of  licalthy  mucous  meml)rane.  As  the  disease 
advances,  minute  yellow  spots  of  tubercle  may  be  seen  ilotling  the  in- 
filtrated tissue.  They  form  on  the  mucosa  beneath  the  epil helium. 
As  they  enlarge,  they  project  a  little  above  the  surface,  and,  gradually 
breaking  down,  leave  an  ulcerated  surface.  These  ulcerations  are 
shallow  and  differ  little  in  color  from  the  surrounding  tissue.  As  they 
extend,  the  surface  assumes  an  irregular  worm-eaten  appearance,  and, 
although  there  is  consc(pient  loss  of  tissue,  this  is  less  apparent,  owing 
to  infiltralion  which  prevails  beneath  and  around  the  ulcer.  Any 
granulations  that  occur  are  usually  of  a  pale-pink  color. 

When  the  epiglottis  is  the  seat  of  the  disease,  loss  of  tissue  fr(>- 
qucntly  extends  rapidly,  the  greater  part  or  even  the  whole  of  the 
organ  being  gradually  eaten  away  by  the  ulceration.  The  pallor  of  the 
tissues,  the  shallowness  of  ulceration,  the  results  of  microscopical  anal- 
ysis, together  with  the  local  and  sysJemic  symptoms,  should  render  the 
diagnosis  certain. 

Prognosis. — This  is  exceedingly  grave.  The  large  majority  of 
cases  die,  and,  as  it  is  u-ually  a  secondary  manifestation,  its  presence 
only  adds  s])eed  to  the  coming  fatal  i-sue.  Still,  cases  do  recover,  and 
a  number  are  on  record  in  which  the  laryngeal  tuberculosis  has  been 
completely  removed,  although  the  j)atient  has  ultimately  died  of  orig- 
inal pulmonary  disease. 

After  extensive  personal  ol)servation,  as  well  as  investigation  of 
records,  llosworth  has  arrived  at  the  conclusion  that  the  average  dura- 
tion of  life  in  ])ulmonary  tui)erculosis  uncomplicated  is  three  yeai's; 
complicated  with  laryngeal  disease,  two  years;  and  duration  of  life 
after  larynx  has  become  involved,  one  and  one-halt  years. 

Although  pulmonary  consumption  is,  in  snni(>  instances,  a  curable 
disease,  the  records  of  post-mortems  proving  that  many  people  die  nf 
diseases  other  than  tubercular,  although  exhibiting  cicatrices  within 
the  lung-tissue  arising  from  healed  vomicie,  yet,  when  complicated 
with  laryngeal  tuberculosis,  the  former  always  eventually  proves  fatal. 

Of  late  years,  however,  the  cure  of  the  laryngeal  tuberculosis  itself. 


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DISKASKS    Ol'    TIIK    I.AItYNX. 


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if  taken  early,  is  by  ninny  laryngoloffists  believed  to  be  possible,  at 
least  in  innnl)ers  of  eases,  tlie  life  of  ilie  sulVerer  bein,<,'  tliereby  pro- 
longed. 

Treatment. —  For  general  oonstilutional  treaUnent,  the  demands 
made  in  behalf  oi  laryngeal  tubcreulosis  do  not  differ  from  those  re- 
t|uired  when  the  disease  is  located  in  otlii  r  organs  of  the  ])ody.  Our 
province  here,  however,  refers  to  the  diree:  treatmcnl  of  the  local  dis- 
ease. In  the  early  history  of  cases,  and  before  operative  nicasnres  can 
lie  deemed  adviifaljle,  probably  no  nietiiod  of  treatment  is  of  e([nal  value 
to  lliat  of  sprays,  thrown  by  the  atoiniz(!r  directly  into  the  larynx.  Of 
all  the  medicaments  that  can  be  applied  in  this  manner,  I  have  found 
none  so  useful  as  different  percentages  of  menthol  in  albolene.  This 
nuiy  vary  from  2  to  10  or  even  20  jicr  cent,  of  the  stearo])tene  in  the 
oil,  commeiu'ing  with  the  lower  numl)er,  and  gradually  making  the 
l)roportion  stronger  as  the  patient  is  able  to  bear  the  application.  Mven 
after  ulceration  has  commenced  and  the  tis.-ues  of  the  larynx  are  grad- 
ually becoming  disintegrated,  tlie  cleansing  and  soothing  ell'ects  of  the 
drug  thus  a])plied  are  always  grateful  to  the  patient,  Uishop  jn^'fers 
camphor-menthol  for  this  purpose,  wliile  otliers  advise  insulllations  of 
iodoform,  iodol,  aristol,  etc.  When  the  jtain  is  severe,  occurring  so  fre- 
quently as  it  does  in  the  advanced  stages  of  the  disease,  solutions  of 
cocaine  are  recommended  for  local  ap])lication,  on  account  of  the  tem- 
})orary  relief  which  they  insure.  In  the,>e  cases,  intrinsically  lio])eless, 
it  is  undoubtedly  our  duty  to  do  all  that  is  possible  for  the  comfort  and 
physical  relief  of  the  patient.  Lennox  Browne,  Charles  Knight,  and 
nuiny  others  believe  that  much  can  be  accomplished  by  spray-treat- 
ment, and  nu'nthol  in  various  proportions  appears  to  be  the  drug  that 
they  rely  most  upon  in  these  cases,  (juaiacol  in  albolene  or  olive-oil 
ill  30-  to  GO-per-cent.  solution  acts  in  a  similar  manner  to  the  menthol 
and  is  worthy  of  trial. 

Of  direct  local  applications  to  be  a]i])lit'd  by  means  of  the  laryn- 
geal cotton-holder,  the  one  that  is  believed  to  be;  the  most  useful,  and 
receives  the  widest  professional  support  at  the  present  time,  is  lactic 
acid.  It  was  introduced  in  18S5  by  Krause,  and  is  used  in  various 
strengths  from  25-  to  lOO-per-cent.  solution.  It  may  be  applied  to  the 
<liseased  tissue  by  brush  or  cotton-hohb'r. 

Parachlorphenol,  5  to  20  jier  cent.,  in  glycerin  is  another  remedy 
recently  advocated  by  Simonowsky,  a))])liod  as  a  pigment,  and  enzymol 
is  spoken  of  by  Murray  as  a  most  valual)le  adjunct  to  other  treatment. 

Intralaryngeal  surgical  treatment  is  the  most  modern  and  radical 


TI'BKRCI'I.OSIS. 


l(i;{ 


roinedy 
Mizymol 
atmeiit. 
1  radical 


means  advocated  fdi'  tlic  relief  and  cure  of  this  disease.  I)iirerei)t  lines 
of  procedure  liave  been  followed  with  more  or  less  siiecoss. 

First  and  most  jirominent  is  cun'ttennnl.  'Vhm  follow  sulnmi- 
cons  injections,  eh'ctrolvsis.  and  ^alvaiincaiilcry  o|)eralions.  Toirether 
with  tliese  methods,  the  reiridar  throat  treatment  liy  hietie  acid,  hriish- 
ing,  etc..  may  be  associated,  aceordinir  to  tlie  jnd<.nncnt  nf  the  operator. 

As  ])ointc(l  out  by  (lleitsmanti.  liftccn  nieml)irs  of  the  iiaryn,u;eal 
Section  of  the  International  Coni^ress  at  l\ome  advocated  curettemenl 
in  snitably-siliiatcd  cases,  'i'his  is  particidarly  applicable  to  the  aryte- 
noid and  commissural  region-,  in  advocating  this  m(>asnre  he  diics  so 
nnder  the  following  conditions: — 

1.  In  cases  of  j)rimary  tulierculons  aU'eetions  witlioiii  pidmonary 
complication. 

2.  In  cases  with  eirciimserilied  ulcerations  and  infiltratinns. 

3.  In  cases  with  dense,  hard  infiltrations  of  the  arytenoid  region, 
the  ventricular  bands,  and  tnl)erculous  tumors  of  the  epiglottis. 

4.  In  the  incipient  stage  of  pulmonary  disease,  with  but  little 
fever  and  no  hectic  symptoms. 

5.  Tn  advanced  pulmonaiy  disease  with  distressing  dysphagia,  re- 
enlting  from  infiltration  of  arytenoids,  as  the  quickest  means  to  give 
relief. 

Gleitsmann  gives  the  following  as  centra-indications  of  curetto- 
ment: — • 

1.  Advanced  ])ulmonary  disease  and  hectic. 

2.  Disseminated  tuberculosis  of  larynx. 

3.  Extensive  infiltration,  producing  severe  stenosis,  when  trache- 
otomy is  indicated  or  laryjigotomy  can  be  taken  into  consideration. 

The  operation  should  be  done  under  the  free  use  of  cocaine,  and 
by  means  of  Heryng's  double  curette. 

Submucous  injection  of  lactic  acid  has  also  its  advocates.  This 
is  introduced  into  tlie  afTected  tissue  by  an  appropriate  curved  syringe. 
Creasote  in  the  same  manner  is  likewise  advocated  strongly  by  Chapelle. 

Treatment  by  electrolysis,  as  taught  by  Scheppegrell,  is  too  recent 
to  be  worthy  of  strong  advocacy  yet.  Halvanocautery  operations  have, 
however,  been  used  to  advantage,  with  or  Avithout  tlie  addition  of 
curettement. 

Tracheotomy  and  laryngotomy  can  only  he  considered  advisable 
as  last  resorts,  indicated  to  relieve  extreme  stenosis  and  dyspnrea. 

As  said  before,  general  constitutional  treatment  is  alike  whether 
the  disease  be  located  in  the  larynx,  lungs,  or  both,  and  should,  mc- 


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.iiimiimiimaMMBta 


404 


DISEASES    OF    THE    LARYNX. 


(licinally  and  diotetically,  be,  in  the  highest  degree,  of  a  supporting 
cliaracter.  Codliver-oil,  wlicn  jiurified  and  deodorized,  is  by  no  means 
an  iiiiftalatable  agent;  and  is  still  largely  and  wisely  used.  Creasote  has 
long  been  a  favorite  remedy  in  doses  of  V4  cubic  centimetre  two  or 
three  times  a  day  variously  modified.  J..atterly,  however,  creosotal, 
or,  more  correctly,  carbonate  of  creasote,  has  largely  taken  its  place, 
inasmuch  as  doses  containing  several  times  this  amount  of  creasote 
can  in  many  cases  be  taken  without  in  any  way  injuring  the  digestive 
system. 

A  very  eligible  way  of  administering  the  creosotal  is  in  combina- 
lion  with  purified  codliver-oil,  as: — 

1.     IJ  Creasote  carbonato GO 

01.  monli.  oiit ;}G0 

M.     Sig. :    I'.iprht  to  sixtecr.  graiinnes  tliri'O  tiims  a  day  aiter 
iiict  Is. 


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With  the  best  of  treatment  and  care  this  class  of  cases,  as  already 
stated,  cannot,  on  the  whole,  be  considered  hopeful;  yet  much  can  be 
done  to  1  licve  the  sulferings,  prolong  the  life,  and  in  some  '..ay  benefit 
the  iinhappy  victims  of  this  disease.  Guaiacol  is  sometimes  of  l)enefit. 
Small  doses  of  morjihine  and  codeine  may  also  be  of  advantage  in  allay- 
ing distressing  symptoms. 

li.  Lake  (Journal  of  Lariingohgi/,  Uhinohgij,  and  Ololoij!/,  Feb- 
ruary, 18!)!))  says  that,  while  ''general  treatment  is  useless,  one  must 
not  lose  sight  of  the  enormous  aid  one  derives  from  increasing  the 
powers  of  resistance  in  the  body,  and  by  increasing  the  numbers  and 
energy  of  phagocytes  and  white  cor])uscles.''  Local  measures  he  divides 
into  surgical  and  non-surgical.  The  former  consist  in  removing  dis- 
eased portions,  curetting  ulcers,  and  depleting  (vdematous  tissues  by 
puncture,  etc.  The  latter  consist  of  insuillation  of  powders,  painting 
on  or  rubbing  in  of  solutions,  the  injection  into  the  tissues  of  hypo- 
dermic remedies,  and  the  injection  into  the  trachea  of  oily  solutions 
by  syringes  and  atomizers,  in  using  any  "paint"  to  the  larynx  a  brush 
should  never  be  used,  but  always  a  cotton-wool  mop,  for  the  two  reasons 
of  cleanliness  and  cniciency.  J5risk  and  firm  friction  are  required,  and 
all  solutions  should  be  as  strong  as  possible.  When  injections  are  given 
the  temperature  should  be  about  80°  ¥.,  the  j)atient  being  instructed 

1.     B  Creasoto  carbonate   ,^i j. 

01.  morrh.  ojit ,?xi j. 

M.     Sig. :    Two  to  four  teaspoonfuls  three  times  a  day  after  meals. 


Tt'UKIU'l'I.OSIS. 


406 


to  .nl.ale  do.ply,  l.ol.l  his  l.roath  imnuHliatdy  after  thr  ,n,\rtion    and 
"ot  to  mu.h.     The  n.n.liti<,n.  att,.idin,^  h,ryn<,..,l   tuhm.uh.si.l  aro 
;I.VHle,l  ,M(o  s,x  Hiniral  head.:     1.  (Iran.dar  eondi.ion  .d"  voeal  cnr.ls 
^.  Miperdnal  exvnnatinT.  nr  ,dceiati..n.     ;{,  (K,h,„.,.    4.  <I-:dema  and 
superlieialnleeratinn.    r,.    I  .eep  uleeralin,,.    (1.   Mixed  ...de.na  and  deep 
"'^•^■••'•"on-     1"  N"s.  1  ..nd  •>  „n  .nelhnd  of  freatn.ent  has  he.^n  so  olli- 
c'anous  as  infratraeheal  injeelinn.     1„  Xos.  li  and   I  sn.-ieal  treatment 
IS  re.inired  a.  well  as  the  appli,.ali„n  of  paints.    ('n(tinur-r,„,-eps  do  the 
most  elleetive  work.      Forn.ie  al.K.hyde  nr  laei,.  aeidshouhl  be  nsed 
after  every  mtralaryn.^enl  n,K.ratio„  on  a  tiduMvula:'  suh,Vet,  no  matt..- 
Low  small  the  operation.     In  Xos.  5  and  .;  iVietions  and' operath.ns  are 
i.s(dess  as  well  as  inloh.ranl  to  the  patient.     In  su.!,  eases  insulTlations 
of  iodoform  and  orthoforn,  will  have  a  wonderfnllv  soothing?  effect   nar- 
t.cularly  the  latter,  whieh  ,s  noted  for  it.  p^olon^ed  aeth.n      ll  I  a 
iion-toMc  anodyne,  produeino-  anaesthesia  of  the  parts  for  nearly  twenty- 
fonr  hours.     The  pro-^nosis.  nnder  judic.ions  treatment,  is  -.."od  nnd"er 
he  hrsttwo  divisions,  fairly  oood  in  some  of  the  third  and  f.nirlh  varie- 
ties, and  universally  had  in  the  other  two. 

■2r,n 


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C'llArTKll  JAXVl. 


W  ! 


LUl'US  OF  Till-:  LAUYNX. 

I'himary  lupus  ul'  Iho  liirynx  is  nut  .so  nuv  as  priiiiiiry  tuhcrcii- 
losis  of  the  larynx,  althou>jli  Ixitli  are  believed  to  owe  tlieir  orij^in  to 
the  presence  of  ttihorele  bacilli.  As  a  ruli'.  lioweve;-,  it  is  secondary 
in  ils  origin,  l)cin,ii'  derived  from  lupus  ol  the  jiharynx.  which  itself 
liad  been  an  oH'shoot  of  lupus  of  the  skin.  In  this,  too,  it  dill'ers  from 
tuberculosis  of  the  larynx  in  beiii,<r  sequel  to  an  external  disease  instead 
of  nn  internal  one  (Fig.  1  w"-2). 

To  the  comparatively  long  list  of  cases  of  primary  origin  already 
published,  Mayer,  of  Xcw  York,  has  recently  added  two  more.     On 


i 


i  I 


Fig.  122. —  Lupus.    Laryiiiidst'opie  appearance. 
(After  Lennox  15ro\\ne.) 


in^ 


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i. 

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i.: 

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M. 

examination  of  the  report  in  the  Journal  of  Laryngology  in  1897, 
however,  only  one  of  these  could  be  called  purely  laryngeal,  and  the 
other  was  a  long-standing  case  under  the  care  of  ^Morris  J.  Asch,  and 
was  more  pharyngeal  than  laryngeal.  In  this  cast'  the  skin  was  for 
years  unaffected,  and  the  patient  lived  for  eighteen  years,  finally  dying 
of  apical  tubercidosis. 

For  the  pathology  and  etiology  of  laryngeal  lupus,  reference  to 
its  history  as  occurring  in  the  ])hnrynx  will  cover  the  points  of  chief 
interest.  The  only  jioint  that  need  be  further  mentioned  here  is  the 
one  brought  out  by  Lcfferts  many  years  ago,  that  the  first  pathological 
element  of  this  disease  is  essential  hypertrophy  of  tissue.  This  is  fol- 
lowed by  slow,  but  destructive,  ulceration,  to  be  succeeded  by  dense, 
(406) 


LUPUS   OP   TlIK    I.AUYNX. 


407 


I'cncc  to 
oi  chief 
ro  is  the 
loloojical 
is  is  fol- 
y  dense, 


hard  cicatrices      AH  thieo  Cdiulition;^  iiiny  exist  in  the  one  hirynx  at 
the  panic  time 

Symptomatology.— Primary  luiuis  of  tlie  laryiiv  may  exist  fur  a 
long  time  before  developing  symptom?.  Like  its  eoiigeiiers  in  the  face 
and  pliarynx,  it  may  exist  almost  indefinitely  without  piodiieing  pain. 
After  awhile  tliero  may  be  slight  hiisldness,  dyspmea,  and  sorenes.s. 
The  secondary  disease  resend)les  the  primary,  but  it  is  more  readily 
discovered,  owing  to  the  primary  indications.  Iluskinoss  may  arise 
from  involvement  of  the  cords  and  commissure,  and  stenosis  from  the 
intralaryngcal  development  of  the  disease.    Cicatrization  occurs  after 


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A*0 


fa,        r 


Fig.  Vli. — Lupus  of  the  epiglottis  ('/o'lch  objectivo;    Ktirlich-Biondi 
stain).     (After  Lennox  Browne.) 

destruction  of  tissue,  and  this  may  lead  to  laryngeal  strict  arc.    Tlu. 
epiglottis  is  usually  the  part  first  affected  (Figs.  l'.^3  and  VH). 

Diagnosis. — A  laryngeal  examination  will  always  ho  necessary  for 
correct  diagnosis.  It  needs  to  he  distinguished  from  tuljereulosis, 
syphilis,  carcinoma,  and  leprosy.  The  surface  is  pale  and  slightly 
(lidemaious.  TTlcerations  form,  but,  unlike  tuberculosis,  tlu^y  are  fol- 
lowed by  cicatrization  and  consequent  distortion  with  marginal  thick- 
enings. Another  peculiarity  noted  by  Lennox  llrowne  is  that  in  lupus 
of  the  epiglottis  the  infiltrations  are  sometimes  so  heavy  that  they  make 
that  organ  overhang  and  almost  hide  the  inner  larynx.  There  are  no 
systemic  symptoms  as  in  tuberculosis  or  cancer,  and  there  is  no  foul 
secretion  as  in  syphilitic  disease.    In  eastern  countries  it  might  be  con- 


i 


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3 

I 
I 


408 


DISEASES   OF    THE    LAHYNX. 


founded  with  leprosy.  It  resembles  it  iiu)st  in  insensitiveness  of  tissue, 
but  leprosy  never  occurs  in  tlie  larynx  alone.  'J'he  aljseiU'C  of  systemic 
symptoms  slioiild  make  llie  diagnosis  comparatively  certain. 

Prognosis. — This  in  many  instances  is  good,  so  far  as  temporary 
recovery  is  concerned.  Tlie  ))rogress  of  the  disease  is  slow.  Sometimes 
it  may  be  arrested  for  awhile,  and  recur  at  a  later  date  at  the  old  cica- 
trix. It  IS  nut  often  dangerous  to  life,  but,  being  a  manifestation  of 
the  presence  of  tubercle  hacilli,  tuberculosis  of  tiie  lungs  may  super- 
vene to  carry  off  the  patient.  In  some  instances  tlie  disease  itself  has 
been  known  to  ])rodii(e  fatal  stenosis. 


l""ig.  121. — l.ujni.s  <if  tlio  I'piglotliH  ('/..-inch  ubjcctivc;    J'lliiliuh-liiondi 
stiiiiO.     (Aftor  I.L'iinox   ISiowiic.) 


:i| 


I'        I 


li| 


Treatment. — 'I'liis  does  not  materially  ilill'er  from  that  of  laryn- 
g<'al  tuberculosis.  Supporting  measures  to  the  system  are  required, 
though  not  so  loudly  called  for  as  in  the  sister-disease.  Curettage, 
owing  to  I  lie  hardness  of  the  nodules,  lu'eds  to  he  done  more  vigorously 
than  in  tiiherculosis,  but  is  followed  by  bette."  results.  Local  treat- 
ment by  applications  of  lactic  acid,  menthol,  and  creasote  are  of  the 
liighest  importance.  By  the  use  of  one  or  other  of  these  or  all  in  suc- 
cession the  disease  may  freciuently  be  arrested,  gi'ing  the  patient 
months  or  even  years  of  relief.  When  operation  becomes  nece.-.siry  it 
is  more  V»opeful  than  in  tul)erculous  disease.  Schroetter's  bougies  may 
dilate  the  stenosed  larvnx  in  some  cases.     Tracheotoniv  will  always 


I.l'T'L'S. 


09 


aii'ord  relief  when  life  is  cudangerocl  from  stenosis.  Wlicn  s  v^ro  con- 
striction occurs  in  the  glottic  region,  intuhation  may  he  r^  .^uired, 
thoiigli  some  authorities  claim  lliat  the  irritation  produced  hy  the 
pressure  of  the  tuhe  will  only  accerituate  the  growth  of  the  disease. 


i 


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If 


I  Ik 


I 


Mr 


CHAPTER  LXXVll. 
LEPROSY  OF  THE  AIK-PASSAGES. 

The  Intoriiational  Conforcuce  on  Leprosy  licld  in  Berlin  in 
October,  1897,  gave  to  the  general  profes>ion  almost  the  first  light 
they  have  liad  upon  this  obscure  subject.  Cliick,  of  Sarajevo,  made  a 
report  upon  37  cases  airecting  the  air-passages,  all  taken  from  the  one 
leprous  district;  Jeanselme  and  Laurens,  of  Paris,  based  their  state- 
ment upon  20  cases  of  general  leprosj^,  60  per  cent,  of  which  had  lep- 
rosy of  the  moutli,  nose,  or  throat. 

The  disease  always  affects  the  mouth  or  nose  before  invading  the 
pharyn.x  or  larynx.  According  to  Gliick's  experience,  the  np.sal  cavity 
was  affected  in  90  per  cent,  of  his  cases,  the  larynx  in  70  )-,er  cent.,  and 
the  mouth  and  tongue  in  50  per  cent.  In  the  large  mijority  of  in- 
stances the  skin  is  attacked  much  earlier  than  the  mucous  membrane. 
In  some  cases,  however,  it  is  reported  to  have  commenced  within  the 
nose. 

One  of  the  leading  features  of  leprosy  is  to  attack  (1)  the  epidermal 
structures,  and  (2)  the  mucous  membranes  l)ordering  upon  them,  the 
two  surface  epithelial  coverings  being  always  atfected  before  the  under- 
lying tissues. 

There  are  two  varieties  of  leprosy:   the  nodular  and  the  ana\-thetic. 

*'T1  microscopical  changes  diU'er  somewhat  in  the  two  varieties. 
Those  of  the  nodular,  or  tuberculous  class,  commence  as  an  accumula- 
tion of  lymphocytes  in  the  perivascular  lymph-spaces,  forming  a  net- 
work of  indllration-strands  which,  increasing  in  thickness,  appear  un- 
der a  low  ])ower  as  solid  cylinders  invading  and  absorbing  the  inter- 
vening tissues.  In  section  under  high  power  these  strands  a[)pear  like 
nodules  with  giant  cells,  and  if  stained  by  the  Ziehl-Neelsen  or  Gram's 
method  are  seen  to  contain  bacilli. 

"In  the  anaesthetic  form  bacilli  are  not  easily  demonstrated;  they 
can,  however,  be  seen  in  the  iTiflammatory  cell-tissue  growing  along 
the  ])erineural  lympli-spaces. 

"The  specific  bacillus  of  leprosy,  or  Hansen's  bacillus,  has  certain 
peculiarities  which  distinguish  it  from  bacillus  of  tubercle.  They  are 
(410) 


LKPROSY    OP    THE    NOSK. 


411 


alonfj: 


from  5  to  6  microns  in  longili  and  0.35  to  0.50  micron  in  tliickncss. 
'J'he  rods  are  said  by  Babos  to  be  interrupted  by  non-.«taining,  clear 
spaces,  representing  doubtful  spores.  They  are,  as  a  rule,  readily 
siained  in  silii,  as  may  easily  be  demonstrated  by  the  trituration 
method,  aided  Ijv  boiling  and  digesting.''    (Lennox  Browne.) 

Lei'Rosy  in  tuk  Xosk. 

The  first  symptoms  are  those  of  persistent  cory/.a  accompanied  by 
formation  of  crusts.  The  discharges  contain  Hansen's  bacillus,  and 
are  consequently  contagious.  This  is  tlie  more  dangerous  in  cases  in 
which  the-  nasal  disease  is  primary,  as  the  le])er  is  conseiiuenlly  not 
immediately  aware  of  the  nature  of  the  disease.  Ejiistaxis  is  also  an 
early  symptom.  The  bridge  of  the  nose  1)ecomes  broader  and  the 
cuticle  thicker,  while  the  organ  shortens  in  length,  tlie  anterior  nares 
assuming  an  almost  vertical  plane.  The  disease  is  usually  uf  the 
nodular  type. 

Soon  the  cartilaginous  septum  softens  and  gives  way,  the  bridge 
<lroi)S,  and  the  nose  flattens  with  the  rest  of  the  vi.sige,  as  in  the  case 
of  septal  destruction  from  tertiary  syphilis. 

In  the  early  stages  the  mucous  membrane  is  reddened,  swollen, 
and  liable  to  bleed  when  touched.  In  tl  :att  r  ones,  brown  crusts, 
erosions,  and  muco-pns  are  present.     The  iiictive  lesinus  are  the 

whitish-  or  pinkLsh-  gray,  leprous  nodules,  contracting  foreilily  with 
the  deep  red  of  the  rest  of  the  membrane.    As  the  noduic-s  beconu;  con 
fluent,  they  may  close  up  the  nares,  producing  complete    lenosis. 

When  septal  perforations  take  jtlace,  it  is  by  resorption  and  with- 
out sloughing  or  discharge.  As  the  disease  advances,  ])ronouiiccd 
amesthesia  occurs.  The  sense  of  smell  is  retained,  although  jiallor  and 
atrophy  mark  the  climax  of  the  disease. 

Lupus  and  syphilis  are  the  only  diseases  for  which  leprosy  of  the 
nose  might  l)e  mistaken.  Lupus-nodules  are  firmer.  In  lupus,  al.-n, 
the  nostrils  nuiy  be  eaten  away,  the  !;cptum  renuiining  sullicientl 
tact  to  support  the  nose,  and  always  being  the  last  to  succumb,  while 
in  leprosy  it  is  almost  the  first  to  yield.  Leprosy  also  has  more  an;es- 
thcsia  during  its  progress,  and,  as  tlu'  disease  advaiu'cs,  in\ari;il}]y 
all'ects  the  cuticle  to  a  greater  extent  than  does  the  lupus.  'I'hc  twd 
latter  symptoms  also  distinguish  this  disease  from  .syphilis,  the  gciu'ral 
history  of  which,  with  its  unilateral  development  in  the  nose,  should 
be  sulhcient  to  render  diagnosis  certain. 


M 

it 


li 


; 


t 


' 

1 

1 

,1 

4 

t 

1 

:} 

i 

1 

i 

412 


DISEASES    OF    THE    LAUYXX. 


1    . 

LEl'JiOSY    OF    THE    MOUTH    AXD    rilAlCYNX. 

In  these  regions  siiioolli  patches  are  first  formed,  tu  l)e  .sueceed(>il 
hy  prominent  nodules.  'J'he  median  i'urrnw  of  tlie  tongue  is  said  to  he 
greatly  exaggerated.  Aniestliesia  and  infiltration  of'  irregular  patches 
take  place,  while  the  sense  dl'  faste,  like  the  sen-e  of  snu'll.  is  usually 
retained.  Aloi'ell  Mackenzie,  in  taliulatiiig  the  history  of  i weiity-fivi^ 
cases,  only  re[»orted  dysphagia  as  present  in  one.  Jt  is  fortunate  that, 
so  terrihle  and  loathsome  a  disease  should  entail  so  little  physical  suf- 
fering. 

The  ])haryn.\  is  always  more  or  less  iiillauicd.  JIypertro])hy  of  the 
tonsils  aiul  other  tissues  soon  follows,  to  be  succeeded  at  a  later  stage 
by  atrophy. 

Jlcariug  is  also  likely  to  he  iuipaired,  through  extension  of  the 
disease  to  the  Eustachian  tubes. 

The  diagnosis  from  syphilis  and  lupu.-  must  be  made  on  .similar 
lines  to  those  already  refernd  to.  l''rom  tidn'rculosis  of  the  ])harynx, 
which  it  somewhat  resembles;  the  intense  pain  attending  the  fornu-r, 
with  its  characteristic  high  febrile  action,  should  readily  l)e  distin- 
guished from  the  anivsthesia  and  low  temperature  always  found  in  the 
leprous  iliroat. 

LErilOSY    OF    TlIK    I.AUYNX. 

'J'he  first  appearances  of  this  disease  in  the  larynx  are  usually  in 
the  form  of  little,  gray,  sensitive  nodules  on  the  posterior  side  of  the 
e])iglottis.  At  first,  as  they  produce  no  irritation,  they  are  nnnofieed 
by  the  patient.  Later  on,  as  the  disease  spreads  all  over  the  epiglottis 
and  to  the  arytenoids  and  aryepiglottic  folds,  forming  a  gray,  hanl- 
cned  mass,  respiration  as  mcII  as  vocalizatic  ii  may  be  'nterfenMl  with. 
The  interarytenoid  commissure,  at  first  appearing  like  a  soft  cushion, 
at  a  later  period  becomes  crusted  and  hardened,  a  general  pachydermia 
of  ihe  larynx  having  taken  place.  As  the  disease  advances,  it  is  usu- 
ally impossible  to  examine  witli  the  laryngoscope  the  lower  ])onions 
of  the  larynx,"  on  account  of  the  extensive  thickening  and  fixation  of 
the  ey)iglottis  itself  (Fig.  125). 

When  this  organ  is  eaten  awa}',  as  in  ^laekenzie's  case,  the  dis- 
torted intralarynx  may  sometimes  be  examined. 

According  to  liergengriin,  the  implication  of  the  vocal  cords  does 
not  eome  on  until  late  in  the  disease,  and  sometimes  not  at  all. 

The  experience  of  Lennox  Browne,  from  whose  book  this  chapter 


J,i:i'ltO,sV    Ol'    TIIK    I.AKVNX. 


413 


is  liir^a-lv  laki'ii,  br.ii>;  (Hit  tlial  ol'  iitliii'  obsorvrrs,  that  the  cliaiigL'S 
Miiicli  ru'!«t  occur  in  liic  larvux  are  thosi!  ot  gc'iieral  tliickeiiing  and  less 
nodular  tluin  wlien  found  on  the  pahite,  and  thai  tlie  destruetion  of 
the  I'.alural  tissues,  as  tlie  disease  advances,  is  al\va_v<  more  of  tlie  nalnro 
oi'  alisoi'jition  than  of  nh-eration. 

W'bih'  the  funi'li(jns  (if  plumat inn.  respiratimi.  and   (h'glutilinn 


Fiir.    ]'l't.     I.f'jirosy   ol'  tlie  luiiguc  mid   ('iiij^luitis. 
(l'"ioin  Lennox  l^rowiie,  IS!)!).) 


I     I 


niav  be  iuteifered  with  to  a  \\\<n\'  lU'  Ic-s  extent,  tlie  ])alient  siilfci's 
little,  if  any,  pain  in  this  disease.  Stnii'iural  changes,  also,  appear  to 
affect  the  vocal  cords  last  (d'  all.  'I'he  voice  at  first  is  but  slightly 
altered.  Then  the  higher  tones  may  he  broken,  hoarseness  and  aphonia 
coming  on  at  a  later  ])eriod  in  many  cases. 

Deglutition  is  sometimes  ditlicult,  hut  rarely  painful. 

Respiration  is  always  interfered  with  to  a  more  or  less  extent,  and 


20 


414 


DISKA^KS    (l|-    TlIK    I.AKVW. 


wlicn  till'  vociil  cords  arc  atl'ootcd  may  be;  very  ditlicult,  produciiijj!- 
stenosis  and  nocossitating  tracheotomy  to  prolong  the  life  of  the  i)a- 
tient.  ])r.  Abraham  lias  reported  a  ease  in  wliich  the  glottis  was  re- 
duced to  the  size  of  a  goosc-qnill.  I  )eatli  sometimes  oeenrs  from  (edema 
of  the  glottis  the  result  of  the  disease. 

Treatment. —  .No  treatment  is  curative.  Palliation  is  all  that  ('an 
be  acconi|ilisli(>d.  De  la  Sota  reports  beneficial  results  from  ap})lying 
resorcin  ami  iod(d'iirm  in  ether.  JTygienic  and  dietetic  measiires  should 
be  attended  to.  Lennox  I'.rowne  suggests  tlie  advisability  of  trying 
serum-therapy. 


i    -' 


ClIAl'TKlf  LXXVIII. 


SVrilll.IS  OK  TllK  I.AKVNX. 


I'liiMAHV  sviiliilis  of  ilic  liirviix  i>  sn  v.wc  as  to  he  alinnst  unkiiDW  ii. 


JUKI,  iis  ii  scroiKliirv  lesion,   il    i> 


>f'l(loiii  met   will).     '[' 


ic  (■liict  iiiani- 


iVstaiioii  ol'  tilt'  disease  is  in  the  so-ealleil  tertiary  period,  oecurrinix 
many  years  after  the  development  of  the  pi'imai'v  lesion.  Congenital 
syphilis  of  the  larynx  is  a  rare  all'eetion. 

Pathology. — 'I'ln    pathological  conditions  pro<liiced  liy  syphilis  of 


1"\<X.  liiC). —  Hotniilion  of  i'|ii^'lin(is  from  sy[iliilii  ic  iih  ri;iiioii. 
(From  Hoswcirth.) 

tlif  larynx  are  as  variahle  as  those  found  in  the  upper  portion  of  the 
respiratory  tract,  Avith  the  oxceiition  of  the  extreme  rarity  ol'  the  pri- 
mary stage. 

Tn  secondary  syphilis  theri^  may  he  tlto  deep  congestion  of  tlie 
mncotis  memhrane,  aeeompanied  liy  dryness,  l-'ollowing  this  may 
come  infiltration,  the  swollen  memhrane  (piickly  heeoming  tlie  seat  of 
numerous  sluillow  ulcerations,  resembling  the  mucous  patclies  observed 
in  the  pharynx,  Ijut  (listri])uted  witli  less  regularity.  These  occur  from 
six  montlis  to  two  years  after  the  development  of  the  primary  sore  in 
sonu'  other  part  of  the  hodv,  and  are  onlv  found  in  the  vocal  cords. 

(41,-i) 


H 


Ii 


"  '1 


410 


DISKASKS    Di- 


ll i:    I.AUY.NX. 


Ij^      I 


'I'ho  ulceratiolis  occurring  in  tiiirf  ^[hjxv  arc  ^iniy  in  color,  siirroimdcd 
l)y  an  hypcr.Tinic  red  zone.  Secondary  sypliilis  rarely  occurs  in  the 
larynx  until  several  weeks  or  iiionllis  alter  tiie  apjiearance  of  the 
cutaneous  cru])tion. 

The  tertiary  sta.uc  is  also  marked  by  hypera'inia.  This  may  ho 
followed  by  deep  and  rapid  ulceration,  destroyin,^  cartihiLic  and  sur- 
rounding tissue.  J-'lVorts  to  repair  hy  Nature  produce  severe  contrar- 
lion  from  cicatrization,  impeding  respiration  and  jn'oducing  stenosis. 
The  extensive  destruction  of  the  epiglottis  and  other  cartilages  of  th(> 
larynx,  arising  from  tertiary  disease,  may  end  in  gross  del'orniity  as 
well    (l''ig.    l-.'d). 

<uiiniiiy  luuioi's  are  jirohaldy  th(>  iiin-t  fro(iuent  pathological  for- 


M 


\hi 


i    ! 


94 


Fig.   I'll.-    (-iiutricial  stenosis  of  larynx,  liic  result  of  sypliilitic 
iilcciation.     iKroin   I'.oswuitii.) 

malion  found  in  the  larynx  during  the  course  of  this  disease.  They 
<lo  not  occur,  iiowever,  until  years  after  the  ])rimary  infection.  The 
interval  may  he  over  one  and  even  two  decades,  the  larynx  during  all 
this  long  interval  being  practically  free  from  disease.  Sometimes  the 
gummatous  tumor  involving  one  of  the  vocal  cords  may  break  down 
by  ulceration,  with  extensive  destructiofi  of  the  tissues.  In  others  it 
may  continue  as  a  dark,  nodular  enlaigement  impeding  the  functions 
of  deglutition  and  respiration.  The  process  of  cure  after  destruction 
of  cartilage  is  aided  by  formation  of  connective  tissue;  but  this  rapidly 
contracts,  resulting  in  the  deformities  of  cicatrization  already  referred 
to  (Fig.  127). 

Etiology. — Syphilis  of  the  larynx  is  usually  a  tertiary,  sometimes 


SM'IIII.IS. 


-ur 


a  secoiuliirv.  niiuiil'cstiitidn  of  ii(i|iiiiiMl  disease.  As  a  priniarv  atroction, 
the  ea-ic  rt'jiortod  l)y  .Miniro,  u!  raris,  in  1S!>0,  appears  to  he  the  only 
oiu,'  un  record.  The  eaiise  may  be  liereditary  as  well  as  accpnred.  Syph- 
ilis of  the  larynx  occurs  more  fre(iuenlly  in  men  than  in  uomeii. 

Symptomatology. — In  secondary  syphilis  nf  tin-  laiyn\  the  symp- 
toms ol'  the  llrst  sta;;e  resenilih'  those  of  siiiiph'  a(  iitc  larynj,ntis.  There 
will  he  soreness  and  hoarscnes-,  and  laryn>,fosc(ipic  examination  will 
reveal  the  congested  condition.  Soon  the  rosy  ap|)earance  becomes 
mottled.  Certain  ])arts  assnme  a  raised  posit  inn  and  sn|)eificial  ulcera- 
tion follows.  The  voice  changes  early  and  the  pitch  is  lowered.  Odyn- 
phagia, as  well  as  hacking  cough  with  expecioral  inn  of  muco-pus.  is 
also  usually  present.  When  mucons  [)atches  are  pri'scnt  they  may  be 
roniul  most  fre(picntly  upon  the  vocal  cords,  then  upon  the  inter- 
arytcnoid  space.  th<'  ventricular  hamls,  and  the  epiglottis.  Cnndylo- 
mata  soniciiuics  occur  in  this  stage.  They  are  u>ually  al)sorl)ed.  and, 
like  the  ulcerations,  are  only  <d'  a  few  weeks'  duration. 

In  the  tertiary  stage  the  deep  ulcerations  usually  alVect  the  epi- 
glottis first,  the  oral  surface  on  the  edge  being  the  lii'.-t  to  sulTer;  ne.xt 
the  intralaryngcal  cavity  and  infraglotti<'  region.  It  is  d\ii'im:  this 
stage  that  guuimata  are  likely  to  develop.  They  consist  of  infiltration 
of  the  dee]ier  layer  of  the  laryngeal  tissues,  sometimes  extending  to 
the  perichfnidrium.  ^^'hen  the  cartilages  are  aU'ected  the  jiain  is  more 
severe  than  when  the  gummatcuis  deposit  is  confined  to  the  epiglottic 
folds  and  ventricular  bands.  When  the  tumor  develops  within  the 
respiratory  tract,  dyspmea  may  follow  as  an  eHV'ct  of  stenosis,  while 
impairment  of  voice  will  result  from  the  disease  alfccting  the  cords. 

Apart  from  the  stenosis  produccil  by  gummatous  enlargement,  it 
arises  much  more  fre(piently  from  the  vigorous  cicatrization  following 
the  ulcerative  process.  S(uuctimc.--  this  is  so  severe  as  to  threaten  im- 
nu'diate  sufTocation.  N'ot  infi'iMpu  ni  ly  a  cieiit  ricial  wcb  foi'ms,  uniting 
the  antei'ior  ends  id'  the  vocal  CMU'ds  logcihci-;  and.  the  slow  chronic 
inllammation  of  the  mucous  nuMubrane  continuing,  the  lunu'n  of  the 
glottis  may  eventually  be  almost  entirely  closed.  Pain  in  these  cases 
is  much  less  severe  than  would  be  expected,  from  the  severity  and 
extent  of  the  diseased  condition. 

Diagnosis. — Tn  the  eai'ly  stages  it  has  to  b(>  distinguished  frmn 
a  simi)lc  catarrhal  laryngitis.  This,  however,  never  extends  to  ulcera- 
tion, and  is  easily  removed  by  simple  treatment,  while  the  syphilitic 
lesion  only  yields  to  specific  treatment.  When  the  mucous  patch  has 
formed,  it  lia^  the  like  distinguishing  features  of  mucous  patch  in  the 


I 


m 


118 


DISKASKS    or    TIIK    I.AliYNX. 


%  j!f '  i^^ 


!* 


'!' 


phaynx.  Tlu'  j;iiiiiiiiy  tiiiiior.  ;is  si'i'ii  in  tin-  Inryiix.  is  a  smooth, 
roimdi'd  tiiiiicliutioii  o|'  liypcrii'iiiif  apiicaiaiicc.  and.  imU'ss  destroyed 
liy  Ircatiiit'iit  or  ulceration,  likely  to  reniaiii  fur  some  tiiiio.  It  is  this 
inaiiit't'station  oi'  the  disease  wliieli  mi^lit  he  iiiislakeii  tor  tul)ereulosis 
or  camel'.  The  diajiiiosis.  however,  is  not  always  easily  made,  in 
tnhereulosis  the  iidiltration  may  l)e  extensive  as  well  as  aiiaMiiic,  in- 
stead ol'  hy|iera'nne  and  circumscrihed.  in  tlu'  one  yon  have  more 
local  ])ain  and  I'ehrile  action.  t(!getlu'r  with  ])nlmonary  lesion  and 
emaciation.  In  the  other  these  symptoms  may  all  he  ahsent,  save  the 
tlilliculty  ot  dciilntition  and  ])rohahle  stenosis.  From  malignant  dis- 
ease it  is  distinguished  hy  the  history  of  the  case;  the  ahst'iice  ot  can- 
cerous cai'hexia.  exuheranci'  ot  j^rowth  and  ha'm(urha,i;'e  >hould  help 
to  make  the  dia^iiosis  certain,  in  all  donhtlul  cases  administration 
of  antisyphilitic  renu'dies  should  help  to  clear  away  the  mystery. 

Prognosis.  -I' nder  pro|)er  tri'atment  this  should  always  he  t'avor- 
ahle,  except  in  cases  in  which  desti'uctive  action  has  already  eom- 
meiu'ccl.  In  even  the.-e  it  may  he  arrested.  When,  howi'ver,  deep 
ulceration  ha>  followed  the  uiimmy  deposit,  cicatrization  is  houiul  to 
take  ])huH',  the  only  hope  lu'inu'  to  prtuuote  altsorptitui  and  arrest 
further  ulccrat  ion. 

Treatment. — 'The  local  treatnu'ut  of  secondary  symptoms  consists 
of  frcciueni  sprays  n\'  a  mild,  alkaline  character,  the  main  ohject  hein;; 
to  keep  iln'  miiciuis  niemhrane  a,~  fri'c  as  possihlo  from  all  irritalinj,^ 
or  I'oid  secretions.  If  the  ulcei'ations  or  mucous  ])atches  persist  in 
devol(^j)meid.  a  nitrate-of-siUcr  ])i,ii'nu'nt  of  ID  ]ier  cent..  ap])lied  on 
a  eotttm-hohh'r,  will  do  li'ood  sei'vice.  tlu'  parts  liavin;,''  heen  previou-ly 
(leadened  \ty  a  solution  of  cncaiiu'.  lodofoini  or  iodol  in  ])owder  hy 
insnfllatiiin,  or  weak  s(iluti"n  n\'  emT(isi\e  -uhlimate  hy  alomizi'r.  is 
also  applied  in  these  ea^es.  ('leausiiiL;  and  disinfectant  treatment  of 
the  larynx  is  always  in  order  in  teniaiy   as  well  as  secondary  disease. 

The  main  reliam-e,  liowe\ei'.  mu^i  lie  placed  on  systemic  treat- 
ment, in  the  earlier  siaL^'es  of  syphilitic  laryngitis  mercurials  arc  in- 
dicated, just  as  when  it  occurs  in  other  pai'ls  of  the  hody.  while  in  ter- 
tiary disease  the  iodides  arc  lU'cded  in  full  and  i'eij,ular  doses.  Some- 
times a  ((Unhination  of  the  two  is  attended  hy  the  hest  results. 

Sui'iz'ical  treatment  is  not  reiiuired  i'Xee]it  in  eases  in  which  strict- 
ure has  hcoome  so  severe  as  to  ])roduce  serious  laryngeal  stenosis.  In 
these  cases  various  nu'thods  of  treatment  may  he  called  for.  It  is  not 
often  that  mendn'anous  tissue  can  he  icmoved  without  danger  of  in- 
ducinir  still  nmre  sei'ious  strictui'e.     Still,  in  sonu^  eas(>s  adventitious 


1    1 

■  ■  ( 

i' 


SVl'llll.lS. 


419 


liiiiids  iiiiiy  l)t'  incised  or  snippi'il  iiwiiy.  As  a  rule,  wlu'ii  stenosis  is 
.se\('re,  laniiiieiil  ililiitois  arc  I'alleil  lor.  Of  the  many  that  have  l)een 
nsed,  Schi'oetler's.  Na\  ratil's.  and  Macl<en/ie",-  are  anionu  tiie  hest.  Tho 
oliject  in  all  is  the  <iradiial  dilatation  of  the  stricture,  the  instrument 
l)eiu<?  ])assod  into  the  hiiyiix  and  retained  as  Ion;;'  as  |)ossihlo.  The 
treatment  should  he  repeated  at  intervals  oi'  a  day  or  two  and  eon- 
tinned  for  months  or  nntil  permanent  advantage  is  secured. 

Other  means  I'ailin.i;-  to  produce  tlie  reipiisite  amonnt  ol'  relief,  in- 
tid)ation  possesses,  in  some  I'cspects.  a  (k'cided  advanlajfe  over  trache- 
otomy, inasmuch  as  it  iloi's  away  with  any  cnttiui;  operation.  It  can 
also  he  ])racticed  hy  mcatis  (d'  reflected  liulit,  and  the  tuix'  worn  or 
removed  at  pleasure,    'i'he  chiel'  disadvaiitaiic  of  a  prolonired  use  oj"  tlie 


.    PI 


l''i;;.    1:2s.      l.ciiiuix    I'.niwiit's   liollnw    lar\  nj^cMl    dilatur   willi    tultiiiy;- 
liliulc    I '   ..   iiicasiiri'iiit'iit  1 . 


instrument  may  he  the  dei'ei'live  deululdion  which  its  insei'tion  in  a 
distorted  laryn.x  may  produce. 

Several  years  aad  .1.  Miuiiit  IMeyer  read  an  exceedingly  interest- 
ing report  to  tlie  Ameiican  Medical  .\ssociation,  giving  the  hist(n'y 
of  tlie  snccessful  treatment  of  eiglil  casi-s  oC  syphilitic  laryngeal  steno- 
sis. In  all  these  he  comhincd  I  he  use  of  Lennox  I^rowne's  cutting 
dilator  with  t1ie  after-inseriion  of  ()"l)wyer"s  tuhes  (l-'ig.  1"2S).  The 
tliroat  is  first  spr.iyed  with  a  ■'"-pcr-eeiit.  solution  of  cocaine,  'i'hen 
the  cntting  dilator  is  inserted,  a  large-sized  throat-mii'ror  heing  nsed 
in  order  to  give  snnicii'nt  rellected  liglit.  l-'or  the  moment  hreatliing 
is  interfered  with,  lint  the  incision  of  the  cicatrix  is  (piickly  made. 
Sliglit  bleeding  follows.  A  few  minutes  later  a  large-sized  hard-rul)her 
intnbation-tn])c  is  introduced  and  worn  for  two  weeks.  It  can  be  re- 
moved once  or  twice  during  that  period,  if  re(iiiired,  for  cleansing  pur- 


'I 


420 


iiim;.\si;s  ok   iiii:  i.Aitvw". 


poses.  In  every  instimec  there  was  grcally-iinprovod  brciithing-Rpnoc. 
Tlie  st.'vcral  innririns  of  eiifli  cicatrix  iicalcd  without  miiiui,  leaving 
an  ahiiost  normal  chink. 

lUeycr  ch)ses  liis  artiele  with  the  following  conclusions: — 

'*].  Jn  the  first  place,  the  destruction  of  the  cicatricial  web,  by 
means  of  the  knife,  is  pri'feraiile  in  every  way  to  the  older  operation 
(d'  simple  dilation. 

"Vf.  Jt  is  a  more  radical  procedure,  and  the  obstructing  tissue  is 
destroyed  (piiekly,  instead  of  being  puslied  aside  and  thus  allowed  to 
slough. 

";5.  'l"ho  operafidii  saves  time,  n  lurc  Ix'ing  cfTccied  with  less 
cliMnoe  of  a  recurrence  of  the  diiliculty.  without  iiicicasing  the  risks 
of  (iperatidti,  than  by  mean-;  of  simple  tli'ali  m." 

Jn  some  cases  of  sy[)hilitie  stenosi>  iraclieotnuiy  may  be  reipiired. 


t.!i 


II  i  : 

(  ■ 


!  ■' 


;1( 


!   ! 


Con<;i:ni  lAL  SYt'iiii.is  oi'   I'lii':  Lakvnx. 

J.  X.  Mackenzie  was  auiimg  the  lirst  to  draw  attention  to  this  ex- 
ceedingly-rare manifestation  of  sy]ihilitic  disease.  lie  says  that  "laryn- 
geal lesions  have  not  been  found  nu)re  fre(|ueidly,  simply  because  they 
have  not  been  sought.  Laryngeal  disease  is  not  rare  in  congenital  syjdi- 
ilis.  It  is  one  of  the  most  constant  and  charactei'istic  of  the  patludogical 
phenomena;  and  we  may  hxik  fiU'  invasion  of  the  larynx  with  as  much 
confidence  in  the  congenital  a.-  in  the  acquired  form  of  the  disease." 
Two-thirds  of  the  cases  so  far  reported  have  occurred  during  the  first 
year.  The  younger  the  ])aiient,  the  more  rapidly  fatal  the  malady. 
'J"he  chief  symptoms  are  impairment  of  voice,  catarrhal  cough,  em- 
barrassed breathing,  painful  and  dillicult  deglutition,  freqticnt  laryn- 
gismus, and  general  wasting  cachexia.  l">equently  the  only  positive 
diagnosis  can  be  made  by  anlisyphilitic  treatment  by  mercurials  or 
iodides,  or  both  cond)ined.  When  adenoids  block  up  the  respiratory 
passages,  they  should  be  removed  while  systemic  treatment  is  in  prog- 
ress. In  some  cases  res])iration  may  be  so  impeded  that  tracheotomy 
and  even  intubation  may  be  required  to  relieve  and  possibly  save  the 
life  of  the  little  patient. 


ClIAPTKi;   1,\.\1.\, 

NKlltOSKS  (iK  TIIK   I.AIIVW. 

This  ^ulijrcl  iiiav  vny  well  he  (li\i(l(<!  iiiln:  "N'ciirdM's  dl'  Seu- 
silitm"  iiiid  "Nciird^o  (if  Miiiinii."  the  hiiw  r  liciiig  siilijcct  to  a  t'lirthor 
ilivi^idii:  (if  ■•s|iiisin"  (if  tlit;  larviix,  (ir  uvcnictix  ity,  and  "|)aralysi.>"  of 
the  larynx,  nr  diiniiii.-lu'd  activity. 

Ni;i  ifosKs  or  Sknsaiion. 

N'ai'ions  ((inditidiis  df  the  larynx  .-udi  n.<  auiUathci-ia,  liyponi'.s- 
thcsiti,  iiaiirstlicfia.  and  ncui'al;iia — may  be  gi'dniicd  tdUfthor  iindor 
this  liead.  Thi'V  all  indicate  dcpaituic  from  llu'  nuiina!.  liie  form  of 
development  being  the  n-sult  nf  pcr-onal  tendency  in  each  individnal 
case. 

'I'here  is  no  special  pathologieal  condition  indicated;  hypera'mia 
may  or  may  not  be  ]ircsent,  Imt  there  is  nsually  a  neurotic  eondilidn 
df  the  system. 

The  cau.ses  wliich  give  vise  to  tliese  conditions  are  numerous. 
Excessive  smoking,  alcoholic  indulgence,  nnsanitary  conditions,  in- 
ordinate use  of  the  voice,  and  liyperlrophicr  cdiiditidiis  df  the  nose  or 
naso-pliarynx  may  be  mentioned  as  the  most  cdinindii.  Of  lU'uralgia, 
a  rheiinuitic  or  uric-acid  diathesis  is  a  fr('(|ucnt  cau>c. 


The  symptoms  are  those  of  lai'yngeal  irritation  of 


duc   idrm  or 


an 


other,  often  accompanied  by  dryness  df  the  thmat  and  a  teiuleucy 
to  cough,  .\nfesthesia  may  be  an  exceptiiin  in  this  rule.  ina:>much  as 
laryngeal  accumulations  occur  almost  to  the  extent  of  obstruction 
without  their  presence  being  noticed  by  the  patient. 

Treatment. — Kxcc])t  in  tlie  hitter  instance,  this  slionid  be  of  a 

will  soothe  tlie  irrita'ile  larynx, 
witluiut  injurv  to  the  general  svstem.  will  be  of  benelit.     Tal)lets  of 


palliative  character.     Anything  that 


chlorate  of  potassa  or  muriate  of  ammonia  dissolved  ii 


1   the  1 


nouth  are 


often  useful.    Menthol  lozenges  containing  V'4  to  '/.  per  cent,  of  men- 
thol are  likewise  soothing  to  the  irritated  parts. 

In  the  ana>stlietic  larynx  stimulating  the  laryngeal  nerves  by  elec- 
tricity may  be  of  benefit,  together  with  the  administration  of  strych- 
nine, arsenic,  or  phosphide  of  zinc. 

(421) 


ii 


I 


422 


])isK.\si:s  ut"  Tin;  i.akvnx. 


Ill  the  ii('iii'al,i,n('  larynx  tlu'  cause  si. mild  Itc  invostigatt'd  and  ro- 
movod.  'I'lcatnii'iit  hy  llie  galvanic  current,  the  inU'alaryngeal  elec- 
trode heing  used,  in  .sometimes  bendicial  in  these  cases.  In  rheumatic 
or  uric-acid  ease-  the  saiicvlates  iiiav  \)v  of  aihantaire. 


I- 


I 


NEUVOI  S    Al'llOXlA. 

Xervdus,  or  liyslerical.  ajihonia  is  a  I'liiictioiial  alVectinn  of  the 
adductor  nuiseles,  giving  rise,  for  the  time  being,  to  complete  loss  of 
voice.  In  it  there  is  no  patliological  lesion.  'J'he  vocal  cords  are  still 
controlled  by  muscles  and  nerves,  anatomically  ami  pl.ysiologically  in 
a  normal  state;  hut,  owing  to  the  hysterical  condition  of  the  patient, 
the  psychical  power  oi  co-ordination  i^  lost,  and  no  amount  ut'  effort 
on  the  ])art  of  the  patient  can  juoduce  the  natural  voice. 

It  seems  to  he  a  functional  bilateral  paresis  of  the  lateral  crico- 
arytenoid and  the  thyroarytenoid  muscles:  the  adductojs  nl  the  larynx. 
It  is  a  disease  jteculiar  to  women  of  nervous  temperament,  and  is  one 
of  the  not  infre(i'"nt  manifestations  (»f  a  highly-hysterical  condition. 
While  it  lasts,  the  voice  is  reduced  to  a  whisper. 

Symptomacolog'y. — 'i"he  attack  is  always  stuldeii.  I^'roin  ]ierft'ct 
vocalization,  the  change  to  complete  aphonia  may  be  instantaneou.-. 
At  the  same  time  the  ])0wer  of  audible  laughing  or  coughing,  being  to 
a  large  di'gree  involuntary,  may  be  retaiiu'd.  The  paroxysm  nuiy  cease 
as  suddenly  as  it  cominenced.  To  ])ersons  subject  to  the  aM;''k..e\- 
]iosiire  to  cold  may  induce  a  paroxysm.  So  may  fright  oi'  intcii-e  nerv- 
ous excitement. 

f-aryngeal  examination  will  revt  al  the  true  condition  of  the  Vdc.il 
cords.  Allhiumh  otherwise  healthy  and  normal  in  apjtearaiiec.  ihey 
cniinnt  be  evnily  and  completely  adducleil.  often  exhibiting  a  trem- 
ulous outline. 

The  prognosis  in  these  cases  is  favorable,  though  even  after  cure 
a  temporary  i'l'tuni  at  any  time  is  possible. 

Treatment. -Men I'll  impression  ,vill  sn;, letinies  i'e<tnre  the  vnici'. 
The  int  I'oiluetinii  n\'  a  lliroal  -iiiirror  or  the  spraying  of  the  larynx  with 
a  slini'ihiling  dilution  nuiv  either  of  ihein  so  di,-lodge  the  aphonic  ini- 
piressimi  as  to  restore  liie  power  of  speech.  In  oilu'r  cases  prolonged 
treatineiil  may  be  reipiired.  ('leansin'.i'  and  stimulating  spray-  to  the 
throat,  a|i])lication  of  the  elei-tric  current,  tonini;'  the  system  bv  tlie 
af  ninistr-'dioii  of  stryclipir.e  oi'  valerianate  (d'  zinc  sustaining  diet. 
and  change  id'  air  aii''  scene  may  all  be  reip-'red  befoic  n  >ncces>fiil 
result  can  b(>  accomplislied. 


SJ'As.M    Ol-    TUK    t..l.UlTlS. 

Xki'kosks  oi'  Motion. 


4:23 


•  1 1  ro 

lici'. 

with 
iiii- 

tlio 
tlio 
li.'U 


spASNf  OF  Tin;  (II. orris. 

As  Sir  .Mdi'cII  Mncknizic  i-ciiiiii'krd,  it  i>  iiiipoitiiiil  to  licar  in  iiiiinl 
lliiil  this  i.<  iKit  ill  il^cll'  a  di^ra.-c.  Inil  a  syiiiptoiii  of  (lisca.sc.  its  usual 
iiiaiiii'cstation  Ix'iu',''  in  tlio  I'onu  ol!  sjiasiu  of  tlu^  glottis,  or  laryii- 
i,nsnuis  stridulus.  'J'lic  uatuic  of  lliis  atVeclioii  is  varioiislv  estimated 
by  different  authors.  !Many  believe  that  it  is  of  refle.x  nervous  origin, 
resulting  in  spasmodic  eontraetioii  of  the  adductors  of  the  vocal  cw'ds, 
the  dilliciilt  hreatliing  and  harking  cough  licing  the  result  of  the  con- 
,«equei)t  steiiosi>. 

I  am  afraid  we  have  not  got  much  beyond  .Marshall  iialTs  teach- 
ing of  sixty  years  ago,  that  it  was  always  produced  by  rcllex  action  froni 
iioiiie  region  remote  from  the  lai'viix  itself.  According  to  this  \icw.  it 
oriirinates  "in  the  trifacial  in  teething,  in  the  pnenmogastric  in  iniprop- 
<'rly-fe(l  childi'eii.  and  in  the  spinal  nerve-  in  constipati(Ui.  iiile-tinal 
disorder,  or  catharsis.""  Some  believe  that  the  pathological  lesion  is 
disturbance  within  the  cereiiral  nerve-centres.  Iliighlings-.Taekson  has 
pointed  out  that  the  nervc-cenires  may  not  be  knit  m)  closely  toLiethcr 
41S  ill  the  adult,  and  that  a  partial  cnnviilsioii.  ,-iich  a-  occurs  in  laryn- 
gismus, point.-  to  the  ■uiperfect  union  of  the  dilVereiil  secti(Uis  of  the 
nervous  system.  The  carpopcdal  conirattioiis  in  children  are  ex))laiiied 
in  the  .<ame  way.  'I'lie  nerve-centres  not  being  fully  (h'veloped,  spasms 
of  muscles  or  of  gmnps  of  muscle.-,  and  c\cn  general  cuiu  ul.-ituis,  occur 
more  readily  and  fi'e(piently  than  they  du  in  adulls. 

Etiology, — This  is  a  disea-e  es.-eni  iaih'  ]iertainiiig  to  child-life. 
It  usually  occurs  between  the  ages  of  tlii'ee  niontli^  and  three  \car-. 
About  t>»ice  as  many  boys  are  ail'ecled  as  gii'l-. 

Physical  orii'anizalion.  whieh  i-  f!'e(pienlly  a  I'c-iilt  of  .-ocial  con- 
dition, has  a  ih'cidcd  inlluence  a-  an  ctinlogical  factnr.  Ill-nouri-hed 
children,  living  (Ui  pnni'  \tu>i\  and  in  ill-\('ni  ilatc(i  hou^i's.  are  particu- 
larly liable  to  ciuitract  il.  In  tl.:'  dcn.-ely-popidated  cent  'e-  of  large 
cities  it  is  more  ]U'i'\alcnt  than  in  nthcr  rciiion-.  When  bad  hygienic 
<Minditions  and  '"nsiinicient  noiii'i-lnncin  are  constart.  the  dll'spring  (d' 
the  ])cople  have  a  tciidi  mcv  tn  rachil  ic  di-ca>e.  .\s  a  result  a  large  pro- 
portion (d'  the  cbiliireii  who  iiave  -pa.-mndic  ci-unn  are  like\\i-c  \ictiin- 
(if  rickets. 

Symptomatology,  The  first  atta  k  of  spasm  or  closure  of  the 
glottis  usually  occur.-  al  nighl-timc.  The  child  is  taken  with  siuhlen 
convulsive  aeti<ui  cd'  the  adiliictors  of  the  glottis.     l'"or  toe  time  being, 


H 


it 


424 


1)Isi:.\m;s  ok  ihi:  i.auvnx. 


^ 


r('s|iir;iti(in  is  iirrcatiil.  niort!  or  loss  coiiiiilotcly.  Tlie  hands  and  foot 
arc  clindicd,  the  licad  tliinwn  liack,  and.  if  loiii,'  conlinncd,  the  face; 
may  hcconic  cyanotic,  lii  a  U:\\  seconds,  or  mijiules  at  the  longest,  tlie 
adductor  nmsch's  ol'  the  Jarynx  yield,  llie  aluluctors  come  again  into 
action,  and  respiration  returns,  sometimes  gradually,  with  long,  crow- 
ing i)r('alliing,  and  sometimes  sudck'iily. 

These  attacks  vary  in  dui'alidii  and  also  in  rretpiency.  When  the 
spasm  is  jmri'ly  neurotic,  relief  may  l)e  c()m})lete  tor  a  time,  occurring 
again  at  irregular  intervals  cd'  hours  or  days.  When  the  stridulous 
hreathnig  arises  from  suhglottic  inflammation,  the  stenosis  will  ho  less 
compk'te,  and  at  tlie  same  time  more  pi'olonged.  never  leaving  entirely 
imtil  the  inflammatory  cause  is  removed. 

Laryngeal  spasm,  although  rarely  so,  is  sometimes  fatal.  C.  If. 
Hunter  (Ih-itish  Medical  Journal.  .April.  1SJ>8)  gives  the  history  of 
two  remarkahle  cases.  These  occurred  in  hrother  and  sister.  Both 
were  perfectly  well  up  to  a  few  ndnutes  hefore  death,  and  they  died 
within  two  days  of  (>ach  oIIut.  The  mother  took  the  1)oy,  aged  1!) 
months,  up  to  wash  him.  in  a  lit  (d'  passion  he  threw  h.i-  head  hack 
and  hecame  livid  and  rigid.  Jle  wa>  put  in  a  hot  hath  at  (incc  l)ut  it 
was  of  no  avail.  Two  days  later  tlie  sister,  aged  7  months,  suddenly 
hecame  rigid  and  hlue  in  the  face,  and  died  like  her  hrother.  withotit 
utti'ring  a  .cound.  In  hoth  there  wci'c  well-marked  carpopedal  con- 
tractions, l)ut  no  genei'al  convulsions.  I'osl-mortem  examination^  were 
held,  hut  all  the  organs  were  found  healthy,  'i'here  were  no  lai'yngeal 
ohstruclion-.  hut  in  hoth  were  indications  of  rickets.  Trederic  Taylor 
says  that  rickets  occur  in  7,")  per  cent,  of  all  cases  of  laryngismus  strid- 
ulus. 

Diagnosis.—  When  ihc  .-|ia>m  is  purely  neurotic  the  diagnosis  is 
not  dillicult,  as  the  exaeerhation-  are.  a.-  a  lule,  follow*  d  liy  perfect  re- 
lief.    Thei'e  is  no  fclu'ile  action  and  no  changx'  in  voice. 

Paralysis  of  the  ahdiuMius  might  jirodiuc  similar  crowing  symp- 
toms, hut  in  this  case  tliere  woidd  he  no  exacerl)alions.  Stenosis  would 
he  continuous  witluuit  fever  ;iiid  without  vocal  change.  P'rom  the 
stenosis  ]M'o(lueed  hy  the  jji'eseiu'c  of  laiyiigeal  papillomala.  the  gen- 
eral histoiy.  together  with  laiyngeal  examination,  wiudd  I'cnder  the 
diagnosis  jdain. 

Prognosis.-- lii ke  ihe  eron)iy  symploms  ai'ising  from  sidjgloltic 
inflammation,  this  is  u-ually  favorahle.  .\  large  majority  of  cases  get 
well.  When  the  spasmodic  action  of  the  adductors  is  compleii\  as  well 
as  prolongeil,  the  result  may  he  at  once  fatal,  as  in  the  cases  referre(l 


;    I 


STASM    Ul'    JllK    (JLOTTls. 


426 


to.  This  rarely  ofciirs.  Tlie  .spasms,  altliuugli  repeated  several  liiues, 
usually  disappear  even  without  treatment.  The  i'riends  of  the  little 
patient,  however,  become  alarmed,  medical  advice  is  obtained,  and  the 
cure  hastened. 

Treatment.- -d"(U'  piii'c  nervous  spasm  of  the  <>-lotlis.  imiiiediale 
inhalation  of  a  few  drops  of  amyl-nitrate  or  chloroform  may  he  li'ied. 
Of  cour>e.  this  wnuhl  haxc  no  eflVct  if  the  glottis  were  coni|)letely 
closed.  A  (luiek  ship  on  the  l)ack.  dashing  cohl  water  in  the  face, 
jdunging  llie  lilth'  ]iaticnt  into  a  hot  hath,  may  all  lie  tried.  Hypo- 
dermic injection  f)i  minute  doses  of  aporaorphia.  a  milligramme  for  a 
child  of  ihi'cc  years,  may  also  ])i'oduce  diaphoresis  and  vomiting. 

.\-.  however,  the  spasmodic  closure  of  the  larynx  is  only  a  symp- 
tom of  cetitral  or  ])cripheral  disturbance  of  the  nervous  system,  mere 
treatment  of  this  symptom  should  not  stillice.  An  attempt  should  be 
made  to  ascertain  the  real  seat  f)f  the  evil,  and,  liy  n'moviuL:'  il.  pi'cvent 
the  recuiTcnce  of  the  attack, 

i-luslaee  Smith  in  the  London  Laiiccl  for  Maich  I'.i,  lS!tS,  gives 
the  history  of  a  case  of  constant  laryngeal  stridor  in  an  infant,  caused 
by  the  presence  of  adenoid  vegetations.  l''rom  the  age  of  (Uie  month 
to  four  months  the  strid(U'  had  been  constant  day  and  Jiight.  Much 
of  this  tinu'  was  spent  in  the  hospital,  but  no  relief  from  the  conlinued 
croaking  breathing  could  be  obtained.  Then  the  adenoids,  whitdi  were 
not  large,  were  removed.  At  once  the  night  attacks  of  acuie  dyspno'a, 
which  for  thr(>e  months  had  constantly  occurred,  ceased,  and  the  child 
sle])t  undisturbed,  in  a  fortnight  the  croaking  during  the  day-time 
eotdd  not  be  heard  in  ordinary  breathing,  and  in  a  few  nmre  days  the 
child  was  discharged  cured.  The  history  of  this  case  is  given  as  a  rare 
and  peculiar  instance  of  constanl  reflex  spasm  of  the  glottis. 

Spasm  of  the  larynx  not  infreiiuently  occurs  in  adults  It  is  usu- 
ally |)ro(luced  by  direet  ii'ritation  ui  some  portion  of  the  lining  mem- 
brane (d'  the  hii'ynx  itself.  'J'lie  ent  I'anec  of  some  ■  light  poll  ion  of  food, 
drink,  or  any  foi'eign  suhstaiU'C  will  induce  a?i  attack.  On  two  occa- 
sions I  have  seen  seven.'  laryngeal  spasm  occur  in  elderly  men  from 
sepai'atiotr  of  a  drop  ol  fluid  from  a  colton-holder.  while  it  was  being 
]ia.«sed  into  the  naso-pbai'ynx.  The  drop  in  eai-h  case  fell  directly  into 
the  open  laiwnx.  and  by  rcllex  action  pioduce(l.  for  a  great  many  sec- 
onds, complete  closure  of  the  glottis.  I  mention  this  from  my  own 
])racti(e  as  much  in  the  way  of  warning  as  anything  else.  Whenever 
application  is  made  through  the  ortil  cavity  into  the  miso-pharynx,  all 
redundant  moisture  should  be  pressed  out  of  the  pledget  Ixjforo  at- 
tempting its  insertion. 


il 


426 


DISEASES    OF    Till-;    LARYNX. 


«;!■ 


-i 


PAKAFA'SIS    (»1-    TllK    LAUYNX. 

I'|(  to  rt'ci'iU  years  it  was  bt'licvod  that  the  abdiicttir  or  adductor 
inusck's  iiiijrlit  citlicr  ol'  tlicm  be  atl'eeted  from  lesion  of  th(!  nerve-suii- 
ph',  to  tlie  exclusion  of  the  ojiposite  group.  .\lso,  that,  in  otlier  cases, 
the  central  lesion  nii.Liht  be  so  general  as  to  aH'cct  all  the  motor  nerves 
of  the  larynx,  inducing  paresis  (d'  both  abductors  and  adductors  at  the 
same  time. 

Since  that  period  o])inions,  based  upon  extensive  clinical  research, 
have  nndergone  a  material  change.  Now  it  is  known  that,  in  jiaralysis 
of  tlie  larynx,  the  abduct(U'  muscle,  the  jiosterior  cricoarytenoid,  is  al- 
ways tlie  one  first  afTected  and  that  the  term  paralysis  ol'  the  larynx, 
as  u>ually  applied,  signifies  jiaralysis  ol'  one  or  both  of  the  abductor 
juuscles.  Further,  wlu'ii  paralysis  of  the  adductor  does  occur,  ii  is 
always  secondary  to  ]iriinary  paralysis  of  the  abductor,  exce])t  in  cases 
where  the  lesion  is  complete  at  once,  as  in  section  of  the  recurrent 
nerve. 

Sir  l'"clix  Si'iuon  suii..,iarizi'S  this  conclusion  as  follows:  '"While 
there  is  not  a  single  authenticated  case  on  record  in  which  it  has  been 
shown  by  post-morlem  examination  that  in  a  slowly-progressive  or- 
ganic lesion  of  the  motor  nerves  (d'  the  larynx  the  adductors  had  been 
])rimarily  or  exchisively  aiVcctcd.  we  are  now  in  possession  of  (juite  a 
number  of  well-observed  case^  demonstrating  the  opposite  order  of 
events."  That  is.  in  whiih  the  abductors  had  been  primarily  or  ex- 
clusively all'ected. 

Semou  adduces  another  curious  fact,  that,  although  in  general 
paralysis  (d'  the  lai-ynx  the  ai)ductors  are  always  affected  first,  when 
recovery  occui's  the  adductors  lead  the  way.  The  reason  assigned  is 
that.  fr(uu  stunc  cause  still  unknown,  the  abductors  arc  much  more 
vulnera1)le  to  nervons  inlhi.  ncc  than  the  adductors. 

The  recent  physiological  investigations  of  Kisieii  Hussel  have 
proved  that,  while  the  recurrent  laryngeal  nerve  is  the  motor  nerve 
par  r.vccUi'nrc-  of  the  larynx,  it  can  be  split  for  its  entin^  leimlh  into 
three  dilTeicut  itundlcs  (d'  librcs.  one  of  which  supplies  the  abductors, 
another  the  adductors,  while  the  third  is  without  motor  influence. 
The  fibres  which  supply  the  abductors  of  the  vocal  cords,  being  situ- 
ated on  the  inner  side  of  the  nerve,  an  thus  coin[)letely  dilTerentiatcd 
from  those  supplying  the  adductor  muscles. 

In  the  large  majority  of  instances  paralysis  of  the  vocal  cords  is 
at  first  unilaieial.  and  fi'(uu  its  pathological  condition  would  produce 


rAHAl.YSlS    OF    Till-;    AHDrCTOU    MI'SCI.KS. 


■i'i: 


no  >yiii|)t(iii/s  wliich  would  be  likely  to  lead  to  imniodiutc  discovery. 
Nothing"  short  ot  laryngol(\ii,i(al  (•xaiiiiiiatioii  coidd  make  [Kwitivc  its 
t'xistciK't.'. 

In  the  first  t-taijc  of  paralysis  the  cord,  which  at  rest  would  he  in 
the  cadaveric  jiot-ilion,  leavinjj  abundance  of  room  for  ri'S])iratioii, 
woiihl  bo  drawn  to  the  mesial  line  by  the  adductors  in  phonation. 
Later  on,  if  tlie  adductor  muscle  remained  unalVecied.  tin-  constant 
tension,  unopposed  Ity  the  abductor,  woidil  lead  to  peruiniicnt  reten- 
tion of  tlie  atfected  c«u'd  in  the  mesial  line.  N'ocalization  wduld  still 
be  perfect,  while  rcs])ii'ation  would  only  he  slii^ditly  atfected.  the  o[)en- 
U)ii  made  in  the  jilottis.  by  the  unall'ected  aliductor  of  the  opposite 
siih'.  still  bein.i,'  sullicient  for  i)reathin^'  purposes. 

^Vhen  paralysis  of  the  abductor  is  followed  by  extension  of  the 
lesion  to  the  adductor  muscles,  the  cadaveric  position  on  that  side  bo- 
comes  ]iermanenl.  This,  of  course,  would  lea\e  the  hreathinu'  s[)ace 
unatfected.  and  would  alVect  the  voice  but  little,  a-  the  unalVected  cord 
iliiriiiii'  ]ihoiiation  would  sweej)  across  the  mesial  line,  to  adjust  itself 
to  its  paralyzed  fellow.  I!en<e.  even  in  this  extreme  case,  (udinary 
symptoms  Avould  not  indicate  the  true  condiliiui  nf  the  vocal  cords. 

In  case-  where  the  ]»aralysis  is  bilateial.  but  in  the  primary  stajxe, 
alfcetin<r  only  the  posterior  cricoarytenoid  or  alidudor  mu-eles.  vocal- 
ization will  still  be  little  interfered  with,  as  the  c<uils  are  adducted  to 
the  position  re(|uired  for  tlio  productiiui  of  sound.  l\espiiali(-n.  how- 
ever, is  seriously  obstructed.  'I'he  bi'eathiiiL;  is  lalxu'cd.  even  to  the 
extent  of  impemlinu'  sulVocatiou.  Wlu'ii  to  this  is  added  adihictor 
paralysis,  the  breathing"  may  be  soinnvhat  easier,  as  iioth  coi-ds  are 
immovably  tixed  in  the  cadaveric  position:  l)Ut  with  the  chan-c  the 
voice  is  completely  lost. 

Laryui^-oscopic  examination  >honld  in  all  cases  be  mailc  when 
there  is  reason  to  suspect  tlu^  ])resence  of  jiaraly-^is;  and  by  it  the 
extent  of  loss  of  powi'r  shmdd  lie  at  once  ascertained,  if  an\  really 
exists. 

'^Phe  causes  of  paralysis  are  numerous.  In  bilateral,  the  lesion  is 
usually  central  and  may  arise  from  th(>  jiresence  of  <;iimmata,  sclero.'^ip, 
tumors,  proirrcssive  inilhar  paraly-i-.  elTnsions  at  the  nerve-origin,  etc. 
Diplitheria  is  not  infrequently  the  cause. 

In  unilateral  paralysis  the  cause  is  rmu'c  freiiuentlv  pressure  upon 
some  part  of  the  course  of  the  nerve  itself,  as  from  aneurism  id'  the 
arch  of  the  a(u1a.  hypertrophied  irhinds  in  malijrnant  disease,  tuber- 
eulo.sis,  etc. 


r 


Ifi 


428 


DISEASKS    OF    TllK    LAltYNX. 


I     111 


il 

i 

': 

'i 

r  1 
:  1 

i 

'.riie  prognosiri  in  jiaralysis  of  the  larynx,  wliolhcr  uiiilatoral  or 
bilateral,  is  not  usually  favorable.  As  a  rule,  it  is  but  an  indication  of 
the  preseiu-'e  of  some  central  or  peripheral  lesion  that  is  itself  incurabk'. 
When  the  paralysis  is  but  the  sequel  of  diphtheria  or  one  of  the  other 
exanlheniatous  diseases,  tlie  outlook  is  more  liopeful;  also  when  arising 
from  the  presence  of  gummata. 

Treatment.- -When  aiising  from  ])ressure  upon  tlu!  rcciirrenl 
laryngeal  nerve,  the  removal  of  the  ])ressure  either  by  excision  of  tumor 
or  absorption  of  gummatous  deposit  should  restore  to  the  posterior 
cricoarytenoid  its  normal  m/rvous  sujijily.  For  the  latter  iodide  of 
polassa  should  be  freely  given.  Jii  di[)iitheritic  cases  strychnia  in  sus- 
tained doses  will  have  a  good  eU'eet,  and,  in  both,  electrical  treatment 
should  aid  in  restoration  of  muscular  power.  The  i'aradic  current  to 
the  interior  of  the  larynx,  anicslhetized  hy  cocaiiu',  will  be  followed  by 
good  results  in  nuiny  cases  of  functional  origin,  tlie  negative  pole  being 
applied  to  the  paralyzed  muscles  within  the  larynx,  by  aid  of  the  laryn- 
goscojje,  aiul  tlie  ])ositive  pole  with  a  large  tlat  electrode  to  the  external 
larynx. 

Systemic  means  to  restore  the  general  health  are  also  required  in 
these  cases. 

For  ancurismal  and  tubereular  cases,  as  well  as  those  arising  from 
central  lesion.s,  little  can  lie  done  save  of  a  geiu-ral  ebaracter  for  re- 
cuperative treatment. 

George  V.  Hoss.  of  Montreal,  has  recently  reported  a  case  of  bi- 
lateral, abductor.  laiTJigeal  paralysis  in  a  nuin,  aged  50,  arising  from 
chronic  alcoholism  of  long  '^taiuling.  'I'lie  treatment  consisted  of 
full  diet,  together  with  sedatives  and  tonics.  The  local  treatment  was 
by  galvanism  and  faradism.  'J'ho  result  was  very  satisfactory,  as  the 
chink  widened  materially  under  treatment,  freeing  the  patient  from 
his  suffocative  attacks. 


n 

1  s 
ji 

U 

1 

11 

1                    :            ! 

1 

tmd 

CllAi'THlJ   LXXX. 


N(l.VM.\I.[(i\.\NT  TlMOltS  OF   TlIK   I.AIIVW. 


Sri;('iMKNS  of  nearly  all  llic  varieties  ni'  l)eiii,L:ii  Iiiiiinrs  have  been 
found  within  the  larynx.  'J"he  niajniity  of  these,  however,  are  excoed- 
in,i,dy  rare.  Papillomata  are  the  most  fre([nent  in  oceiirrenee,  with 
iihroniata  ]irol>al)ly  as  seeoiul,  while  eases  of  cystoma,  myxoma,  lipoma, 
c'iK'lioiulroma,  and  aniifionia  are  amom;'  the  rarest  of  laryngeal  all'ee- 
tions.  I'atholoii'ieally  thi'se  various  neoplasms  are  the  same  as  when 
I'onnd  in  the  nose  or  naso-jiliai'ynx.  the  diU'erence  in  condition  heing 
one  of  site,  and  not  of  history. 

I'aiiilloniata  may  occnr  at  any  pei'iod  of  life.     'They  occnr  most 


ii 


Pig.   121).-    I'iipilloiiia  of  (111(1  I'io.    i;i(i.     Smiiic  (lining  [ilio- 

duriiiji!-  rcspiinlioii.  iiiitioii. 

I'iiticiil   iiiiilt',   agp(l    55.     Entirely    iciiiovi'd    liy    lucal    a|ii>li('ati(iii    of 
astringents.     L'nder  treatment  one  year.     No  veeiiirenee.      (Author's  case.) 


t        1 


frequently  dui'ini;'  ehildliood  and  mature  years.  Tlieir  site  is  usually 
the  vocal  cords,  and  they  may  be  single  oi'  niulti|)le.  They  dilVer  in 
color  also,  from  pink  or  ligld  red  to  gray.  Tn  early  life  they  are  ordi- 
narily of  a  bright -ri'ddish  color,  and  may  exist  in  largo  numbers.  Al- 
though usually  sessile,  with  a  warty  appearaiu'C.  they  are  sometimes 
pedunculated.  In  adult  life  they  oftt'U  occur  singly,  being  attached  to 
the  margin  of  one  of  thi>  vocal  cords  (Figs.  rj!>  and  bid). 

In  childhood  I'eeuri'ence  after  removal  is  fic(pieid.  while  in  adidt 
life  it  is  rare. 

Fibromata,  although  occurring  with  mucli  less  frequency  than 
papillomata,  are  also  usually  attaehed  to  tlu^  vocal  cords.    They  never 

(429) 


27 


' 


luO 


i)i>i:\>i>  (»i'   riii;  i.akvnx. 


occur  in  cliiUIhood.  'I'licy  iirc  linrd  in  (cxlurc,  <.'mv  or  (loop  red  in 
color,  and  inav  bo  attiuliod  oilhor  by  ii  broad  pedicle  or  a  wide,  sessile 
ba>c.     After  complete  removal  tlioy  seldom  rocnr  (Kif,'.  131). 

Of  tlic  otlior  varietie?  of  boni,i,ni  tumors,  the  cysldina.  while  e\- 
cecdin<f|y  rare,  occurs  with  e(iual  fre<[nciuy  \\]u\u  the  epinlotlis  and 
the  vocal  cords.  In  Chark's  Kni^iit's  case  it  (iccurrcd  in  a  colored  man 
aged  1(1  years.  The  cyst  was  pnle  in  color,  with  a  number  of  large 
blood-vessels  on  its  surface.  It  was  round  in  form,  aliout  the  size  of 
a  hick(U'y-nut,  and  attaclied  to  the  left  side  of  the  epiglottis.  The 
Iiiinor  wa-  reailily  removi'd  by  means  of  a  cold-wii'c  snare  without 
liiomorrhage  and  without  pain,  the  throat  having-  been  previously 
sprayed  with  a  10-per-cent.  solution  of  cocaine.  Myxoma  or  polypus 
when  present  usually  a])pcars  on  the  cord,  an<l  the  same  may  be  said 
of  anirionia.     Kuclioiididuia  has  been  observed  on  a  number  of  occa- 


l"i,Lr-  liil.  I'ilniuiia  >itualt(l  licuciitli  llic  riglil  vocal  cord,  occuniiifi 
in  a  man.  a<;c  40,  and  removed  iiy  frctiuciit  ainilicalions  of  galvaiioeautcry- 
jioint.  alter  Inn^liinj.''  caeli  time  with  1.")  |iei-cont.  solution  of  cocaine. 
(,\iitiior's  case,  i 


M 


■  l'    r   , 


^iniis  (l-'ig.  ]'.V!).  'I"he  usual  site  has  bei  ii  the  inner  aspect  of  the 
eficiiid  cartihige.  The  growtli  is  sessile  and  hard,  iiifrinufing  by  it- 
eoiitinue(|  (levelo])ment  upon  the  l)reathin'i'  sjiace.  Lipoma  has  its 
favorite  seat  upon  the  aryepigloltic  folds.  .\s  it  eidargcs.  it  falls  over 
into  the  hyoi<l  fossa  or  toso])hagus.  and.  attaining  groat  size,  threatens 
i-iilTocation  of  the  patient,     .\ngioma  also  siunctimes  occurs  (l''ig.  133). 

Symptomatology.  —  Xcnu?  of  these  growths  are  likely  to  be  at- 
leiided  by  much  jiain.  The  main  symptoms  are  those  arising  from 
obstruction  of  res]iiration  and  phonatioii.  In  certain  cases  de<rliitition 
may  be  affected,  but  only  Avhcn  the  growth  within  the  larynx  is  large, 
oi'  else,  as  in  lipoma,  when  the  (esophagus  or  hyoid  is  int''uded  U])on. 
Cough  is  also  pri'sent  in  mtiny  of  the  cases. 

In  papillonuitons  disease  the  voice  is  usually  severely  afTectod,  as 
the  nco])lasm  is  located  on  the  margin  of  the  cord.    When  the  papillo- 


N(tN-M.\I.I(iN.\Nl'    Tl   MOliS. 


•i;!i 


inata  arc  iiinnciDUs,  the  voice  may  lie  completoly  iiplidiiir  and  the 
respiration  interfered  with. 

\\  lien  tlie  ^n'owth  is  situated  entirely  free  from  the  voeal  eords. 
tlie  voiee  may  not  he  impaired,  although  the  ohstruetin^'  neophism 
may  h(!  hirge  enoujfli  to  jirodiiee  dyspncea. 

Diag^nosis. — This  will  depend  almost  entirely  upon  lai'ynj^osco])ie 
examination,  whieh  should  reveal  the  size,  coh)r,  and  hication  of  the 
j^rowtli.  When  the  dia.unosis  is  still  uncertain,  a  small  piece  should 
be  snipped  (jif  the  neoplasm  to  be  submitted  to  hisiolojfical  examina- 
tion. 

The  main  distinctive  features  which  I  he  larvniroscopc  reveals  are 


II   the 

y  it- 

s   its 

over 

atcus 

VVA). 

c  at- 

froni 

ition 

u'ge, 

uiion. 


(1^ 


tlic   ('iii<,''lc>tt  is.      (After    I'o-^- 
\\  (irtli,  I 


\'\'j:.    l;{;!.      Aiiuidiiia   of  the  Icfl 
:il\  rpi^'lottic     fold.        (After     Jios- 


uortli.) 


as  follow:  A  papillonui  is  >oft  and  ninvidilc  by  in-piialion  and  expira- 
tion. When  siniilc,  it  is  a  <;ray  or  pink,  and,  as  a  rule,  situati'd  u|nin 
the  anterior  half  of  the  vocal  cord.  It  is  usually  sessile,  ahliniinji  ilu. 
base  is  not  very  brf)nd.  When  ninltipli'.  as  in  childi'cn.  llic  iilllc.  ^n['\ 
nuisscs  may  have  a  bi'iuliicr  line,  and  tln'  whole  Icnu'th  of  the  eords 
may  be  studded  witli  iluin.  I  haso  seen  the  latter  condition  in  a  jrirl 
of  ci,iihi('cn  years. 

.\  fibroma  a])pears  as  a  hard.  rounde(l  mass  in  -onie  cases:  it  is 
multilo])ular  in  form  in  othci's.  U  is  usually  sessile  and  may  vary  in 
size  from  a  irrain  of  wlieat  to  a  couple  of  centimetres  in  dianu'ter.  The 
mucous  mend)rane  covering  it  is  ricldy  supplied  with  vessels,  which 
heiglitens  tlie  color  of  the  tumor. 


It 


43a 


JJISEAS1>    UV    TllK    l.AliVNX. 


m 


A  ('Iioiidroinn.  as  said  bcJ'oro,  lies,  in  tlio  majority  of  cast's,  bohiw 
tlu'  vocal  cord,-.  It  also  is  round,  rcsistinir,  mid  nodulated,  but  is 
lighter  in  color  than  cither  ])a|)illouia  or  libronia.  l''roin  its  color  and 
appearance  il  nii^fht  possil)ly  be  mistaken  I'or  carcinoma,  but  t'oi'  its 
occurrence  in  I'arly  lii'e,  while  mali<,Muint  disease  of  the  larynx  occurs 
only  in  later  years. 

A  cystoma  usually  presents  itself  as  a  jxMlnnculated  cyst,  cnni- 
prcssible  iind  soft,  and  of  a  pinkish-,<,'ray  color. 

An<iioma  has  a  red  and  slrawlxMiy-likc  siiifaci'.  while  myxmiia 
looks  Wkr  a  iia-al  polypus  ti'ansfi'rred  to  the  laryii,i:cal  cavity,  but  tinned 
with  a  hi;.;her  shade  of  color. 

Prognosis. — \on-mali,unant  tumors  involve  litiU'  danncr  to  life. 
<'xcept  when  they  assume  such  proportions  as  to  threaten  suiTocation. 
Ill  cliihlreii  papillomata  are  sometimes  produced  in  alai'uiinu'  iiiimher>. 
One  unfortunate  ft'ature  of  their  (le\elopnici  -  that  after  removal 
they  have  a  stroiiu  tendency  to  rcjiroduction.  In  adults  they  can  usu- 
ally be  removed,  iind,  if  the  vocal  cords  remaiii  uuiiijuied,  the  voice. 
when  aH'ccted,  soon  re.iiains  its  normal  tone. 

Treatment. — ^lany  iiisti'iimeiits  have  been  (levise(l  for  opei'ation 
upon  these  beniiiii  neoplasms  when  necessary,  but  ihcy  are  all  intended 
to  be  used  intralaryn<ieally.  .\  uood  laiyn^'oscopic  view  of  tin'  larynx 
having;  been  obtained,  the  iiisti'uiiient  and  method  must  be  chosen  to 
suit  the  case  in  hand,  care  beijig  taken  to  avoid  all  undue  injury  to  the 
healthy  soft  parts  surrounding  the  diseased  tissue. 

Jn  ])a])illomata  after  free  cocaini/.al  ion  astringent  and  stimulating 
sprays  have  sometimes  been  found  benclicial.  |)articularly  in  the  iniilti- 
])le  variety.  Of  these,  ])erhaps.  pure  alcohol  has  the  liighc<t  reputation, 
'rouching  the  single  growths  with  lliiid  extract  of  thuja  occidentali^. 
20-per-cent.  solution  <if  tannic  acid,  '>-  to  J(l-pcr-eent.  solution  of 
nitrate  of  silver,  "'-  to  .-»-])er-cent.  solution  of  sulphate  of  copjier.  or  '2- 
to  o-per-cent.  solution  of  chhu'ide  of  /iiic  might  be  nuMitioned,  and. 
as  a  caustic,  chromic  acid  melted  mi  the  end  oi'  Ihe  applicator  is  ad- 
vocated by  some  writers. 

IV)  eradicate  the  growths,  however,  more  elTectual  measures  are 
required.  Before  o])erating  a  *3()-per-ccnt.  solution  <d'  cocaine  should 
he  freely  applied  to  the  inner  larynx.  Cutting  l"orcc|)s  (i'lg.  l.'?i)  of 
different  kinds  to  suit  each  case,  for  the  renuval  of  pa|)illoiiiata  and 
fibromata,  are  the  most  favored  instruments.  W1<en  the  growth  is 
distinctly  pedunculated,  the  snare  carefully  adjusted  is  probably  even 
more  ofTectivo,  care  being  taken  to  sever  the  attachment  by  the  wire 


'Lii ' 


NdN-MAl.KiNANI'     I'l   M()l!>. 


4:53 


lifforc  tiiu  iiiiuli  t ruction  is  iiindt'.  \'vv\  >iiiiill  .-i/rd  |ia[>illitmiit!i  may 
be  L'xlrai'ti'tl  l»y  tlic  use  of  Sclirocitci's  tiiiic-rorfciis;  Itiit,  I'or  larj,a'r 
growth  •.  ToboldV.  l'"aiiviTs,  or  .Mackcn/iiV  loiccps  arc  itiTlVrrcd. 

I''(ir  cvsloiiia.  fvaiiiatidM  liv  the  kiiilV.  and  >m1)si'(|ii('IiI  loial  [wni- 
iiR'iit  iiy  timtiirc  of  indinc  or  nitrate  of  siUcr.  arc  ad\i>alilc. 

l''(pi'  cncliniidi'dnia  I  he  ;:'alvan(icatitery  ha>  lieen  nscd.  a>  it  i-  al-n 
ill  some  cases  id'  lihroma.  Myxoinata  may  he  snared  or  picked  oil'  by 
laryn<j-eal  rorce|is,  and  suhse(|ucidly  the  site  of  attachnicid  tonched  by 


Fiir.   l;!!.      I'lxliriiiilioii  iiislnnnciits.   i\i;m- 


<■  >  >ct    lit   ID.  ill 


imivcisal  liaiidlc 


tile  ,<ialvanocautcry.     Aiii^ionia  also  iniirht    he  H'eati-d   wiili   tlie  same 
iiistrnmont  at  a  dnil-red  lieat. 

Kach  iiidividnal  case  shoidd  lie  ^i\en  the  nio-i  (jn'el'iil  coii-iihia- 
tion  liy  the  operator;  and  be  treated,  not  accordini;  to  ride,  inn  liy  tlie 
liglit  of  e\j)crieiice  and  npoii  its  ow  n  merits.  It  should  ever  be  I'l'mem- 
bered  tliat  some  of  these  lienijiii  u'l'owths.  if  hd't  to  themselves,  will 
eventually  disa])])ear  or  at  all  eveiit<  become  innoenon-.  |iariicnlarly  in 


cases  wlierc  the  free  use  of  the  vo 


ce  is  not  ol  vital  imporianci 


hiTf 


is  also  the  possibility  of  stimtdatin.u  reproduction  of  the  neopla>m  liy 
operative  treatment;  and.  still  fnrther.  of  inducing'  the  devidoimient 
oi'  malignant  disease  by  oflicious  operative  int(;rference.  This,  at  all 
events,  is  the  view  of  manv  ahle'writers.  among  whom  Lennox  Urowiie 


!  :;i 


434 


DlSKASliS    (»l'     Till';    l.AUVNX. 


i:    'i! 


I-  Ih  ■111 
Cm  I  I 


.-liiiids  iiroiiiiiiciitly  I'nrwiird.  Ndt  tluit  these  operations  srslioiiM  In' 
eseliewed  iillo;^'el  liei',  lillt  tllilt  ii  wise  jlldi^liieiil  siioldd  i)e  exercised  ;d- 
Wiivs  ill  deMliiiir  iiidividiiidly  with  these  cases. 

Ill  iiiiilti|ih'  |iii|)illitmata  of  chihlreii  treatiiii'iit  hy  t  riiehi'otoiiiy  lias 
recently  heeii  received  with  favor.  Iiailton,  in  the  llrillsh  Medical 
'limrnal,  l'"ehriiary.  Is'.is.  irjvcs  the  history  (d'  two  little  i,Mrls  ai^ed, 
res|)ectively,  ;!  and  I  years,  treated  siiecessi'idly  in  this  way.  One  re- 
(juired  to  wear  the  tiihe  I'orty-tive  months  helore  the  <,'rowtlis  were  all 
absorhed;  the  other  for  twenty-hse  inoiilh>.  In  each  the  child  made 
a  ;^()od  recovi'ry  evenlnally,  without  return  (d'  t!ie  pajiilloniata.  Al 
lirst  silver  tidies  were  worn,  then  sol't-ridiher  one.-.  The  latter  were 
reiiewid  three  times  a  week  K'ailtoii  attributes  the  sjioiilaneoiis  atro- 
jihy  of  tlie  ffrowths  to  the  removal  of  the  irritation  of  res|)iration  and 
coughing.  Of  course,  the  jieriod  of  euro  was  prolonged,  but  it  must 
Iio  renienibered  that,  in  cases  where  laryngotoiny  has  been  performed 
to  I'aciJilate  icinoval.  the  growths  have  .-.iil)sei|iiently  in  many  instances 
recurred. 

in  some  cases  it  is  possiiilc  that  piidoiiged  intubation  might  have 
the  eU'ect  of  promoting  alisorption  by  the  constant  jiressure  it  pro- 
duced. Still,  the  dilliculty  of  deglutition  wdiild  lie  a  hinderance.  Tni- 
loiiged  wearing  of  laryngeal  lubes  of  any  kind  has  also  the  possibility 
of  inducing  granulations  and  p(dypoid  growths  'o  form  round  the  mar- 
gins of  the  instriinieiit. 

Thyrotoniy  has  frequently  been  iierforined  for  this  class  of  cases 
in  children,  but   the  results  have  never  been  bi'illiaiit. 

G.  llunter  Mackenzie  (llrilish  Mrilicdl  .loiintdl.  May.  IMi'.i).  in 
Ills  rcinarks  on  laryngeal  growths  in  young  children,  advocates  traidic- 
otoiny  as  the  treatment,  of  all  others,  most  satisaietory  in  tliis  condi- 
tion. He  lays  it  down  as  an  axiom,  that  tlie  two  methods,  so  fre([iiently 
advocated, — removal  per  ria  inili(riilis  and  by  tliyrotoiny. — are  both 
inadmissible,  the  reason  given  being  that  direct  interference  with,  or 
irritation  of,  the  growths  is  almost  always  followed  by  rapid  recur- 
rence. Tlie  endolaiyngeal  method  of  removal  involves  a  prolonged 
series  of  operations,  which  are  usually  followed  by  recurrences,  while 
thyrotoniy,  when  tiied.  has  sometimes  required  to  be  repeated  three  or 
four  times  within  a  year,  ri'siilling  in  more  or  less  ])crmanent  impair- 
ment of  the  voice,  as  well  as  stenosis  of  the  larynx. 

Intubation  is  olqectionable  in  these  casi-s  on  account  of  the  irrita- 
tion it  jirodiices.  It  is  also  freiiuently  dilliciilt  to  retain  the  tube  in 
position. 


NON-MAI.IliNANT    Tl  MOKS. 


i;i:. 


The  iK)iiit  tliiit  lliinlcr  Miickcnzir  insists  upon  is  that  trachcMiiiiiiy 
in  this  disease  is  not  only  a  paUiativi',  hut  alsu  a  eurative,  operation. 

Tiu'  order  ol'  invents  lie  descrihes  as  j'oliows:  First,  tlie  lireathiui,^ 
is  reUeved.  Second,  the  -jrowths,  iieiiit:  freed  from  the  irritation  of 
e()U;.diin;:  and  phoii.ition,  uradtiailv  lo>e  ihcir  vitality  and  heconie  de- 
tached from  the  vocal  cords,  willidiit  any  tendency  to  lecnr.  if  the 
expectoration  ;ind  secretion  from  ihc  windpipe,  as  taken  from  I  lie 
throat  of  the  jiatient  or  from  tlu'  tracheal  wound  when  cleansin-  the 
tulie.  he  examined,  the  growths  will  he  found  to  come  awav  in  picc.'s. 
(Iraduully,  in  peri<ids  varying;-  from  one  nmnlh  to  .-ix  months  oi'  a  year, 
the  papiHomala  shrivel  away  and  linally  dL-ajipear. 

'i'lu;  tuhe  should  not  he  i)ermanently  removed  until  the  growtli- 
are  all  away.  I'his  removal  of  the  tracheotomy-tuhe  is  always  ohjeeted 
to  hy  the  child,  as  at  first  normal  hreathini,'  is  more  dillieiilt  than  the 
artificial.  Consequently,  one  or  two  sIkhi  reinsertioiis  mav  ho  neces- 
sary. In  a  short  lime,  however,  hreathinir  heconies  natural  and  the 
voice  is  i^i'aduallv  restored. 


ii 


li 


tt  i 


('I[Ai''I'!:r  i.xxxr. 


MALUiXANT  Tl'MOIiS  OK  TllK  L\KVN\. 

<>i-  these,  tl)(>ro  are  two  vmieties:  careinoiiia  and  sarcoma.  'I'lic 
lattii-  is  rarer.  oeeurriii<:-  in  alioiit  (Uie-tliird  of  tlic  eases.  The  growth 
of  sareoina  is  the  more  rapiil  (  f  the  two,  ami  it  mav  occur  earlier  in 


i"]'^.    I.'l.').     SiUiuiiiji   (It   the    larviix.   as   seen    Ircuii    licliiiMl. 
(After  Leiiiiox  liroune.) 

life,  while  the  general  -\in|it(iiii-  and  hi.-ioiv  resemhlo  those  of  cai'- 
i-iiioma,  with  the  exception  tliat  it  develops  less  syst(  inic  cachexia  and 
less  inv<dveiiient  of  the  cervical  .inlands  {Vi[x.  i;',")). 

Tlistolon-ieal  examination  alone  can  make  the  diagnosis  jKisitive 
hetween  the  two:  and  tin  prognosis  in  each  case  is  ciinally  unfavorahle. 

Carcinoma  of  the  laivnx.  aithiniL:h  if  oecnrs  more  frequently  tlian 

finn) 


lAKl  l.NO.MA.       SAIICd.MA. 


437 


ill  the  iidsf.  niiMi-|)liiU'VM.\.  iiml  |iliiirviix  ciimliiiird.  \v;i>.  accord iiijj  to 
(iiirlt.  (Hily  rnimd  (iij  time-  in  11. UU  ca>i>  (d'  ciirciiuimiu  (ir  1  in  ITti, 
showing  that  its  IriMjiiciicy  is  eoiiiparativcly  small,  in  comiiarison  with 
its  occurrence  in  other  organs  ol'  (lie  hody. 

Pathology. — The  histology  oL'  ihc-e  two  diMii-.s  is  tlie  same  as 
when  i'ouiid  in  other  regions. 

in  the  larynx  ihe  varit'ty.  in  a  hirge  majority  of  in.-taiices.  is  epi- 
thtdioma.  'i'lu'  r.iost  lre(iiieiit  site  is  the  \entriciihir  hands.  [)roliai>ly 
one-hair  the  cases  oecnrring  in  t'!'-  region,  the  other  hall'  heing  fiiund, 
without  any  ]irecisc  order,  upon  tin'  vocal  cords,  epiglottis,  cmnmissure, 
arycpiglottic  folds,  cic.  '!"hc  variety  of  cancer  foi'iucrly  found  in  the 
larynx  and  called  "  eiU'ej)haloi<r"  would  now  answer  to  the  title  "Vinall- 
cc'lled  sarcoma":  while  the  '■scirrhus""  of  the  larynx  whiili  h'-to'y 
speaks  of  would  agree  with  our  jireseiit  den>e,  ■■>|)indle-cel|e(^  sir- 
c(una""  (  Lennox  lii'ownc).  Ucsides  these,  two  other  varietio  -chondro- 
sarcoma and  luyxosai'coma — are  hoth  somclimo.  lIuuiLih  rarely,  pro- 
cm. 

Of  epithelid  cancer  two  types  are  met  with  in  thi'  larynx:  the 
si|uamous  and  tlic  alveolar.  The  first  is  what  is  called  the  nested 
variety,  the  epithelial  elements  forming  solid  cylindci-  in  the  snh- 
Jaceiit  ti.«sue.  Tiie  second,  nr  alvcoiar.  \ariety  is  very  rare.  Its  name 
implies  its  character,  and  it  (U'iginate<  in  glan<l-ti>siic,  while  the 
siinamons  develops  in  -ti'atilied  epithelium. 

Primary  carciiicuna.  while  cotilined  to  the  inner  lavity  <>['  the 
laiTiix,  shows  little  tendency  1o  invohc  the  glands  (d'  the  neck.  This 
well-known  fad  only  r<dales  to  cancel'  well  wiihiii  the  laiyiiv.-  -foi'  in- 
stance, the  veiilricuiar  hands  and  vocal  cords. — and  dnes  not  apply 
to  the  ilisease  occurring  on  the  epiglottis,  arycpiglottic  folds,  or  aryte- 
noids. When  the  can  ci-  is  located  in  these  regions  the  surrounding 
gland.-:  jii'e  i[iiiekly  aUVcied. 

.\s  i'losworth  has  idi'cady  shown.  Sappy's  anatoniieal  investigations 
<d'  the  lymphatic  snpjdy  to  the  larynx  W(udd  <ecm  to  give  the  rea.'^on. 
\\'liile  tlie  epiglottis  and  the  arye])iglolt  ic  fold-  are  ri(dil\'  supplied  with 
lymphatic  vessels.  the<e  hecoiiie  attciiuale<i  toward  the  \cntricular 
hands  and  vocal  cords,  the  sup|ily  of  lymph  lo  these  heing  \cry  limited, 
the  atteiinatioii  incriMsiiig  with  years.  ('(Ui-eipU'iilly  eaucer  of  the 
inner  larynx  has  less  power  (d'  coinmnnicating  itself  to  the  gland- 
cdemcnts  than  when  it  occurs  in  thi'  nnu'c  richly-supplied  region  ahove. 

Symptomatology. --The  early  symptoms  o\'  carcinoina  and  sar- 
ciuna  do  not  dill'er  widclv  fi'oni  those  atlcndinu'  the  formation  cd'  noii- 


XL- 


I  lis 


i)i.-^i;.\si>  di'    III  I,   I.  \in  \  \. 


lllilllL'li;llll     L!ln\Ull-,       Till'    rllV(  I     ll|i(ill    llli-    \ii|ii'    Will    (lr|ii'lli|     li|h<n    llli' 

Mliiiiliiiii  111'  llir  liiinnr.  Sn  |nii'.;  ;i>  lln'  miimI  conl-  arc  iiiuiII'itIimI,  aii.| 
ran  cliisi'  III  )iliiiiial  hill,  llir  \^^\i.v  may  lie  clear;  Iml  in  iiilriii,-ic  (•aiucr 
ll    -iinli    licciiiiic-    in\ii|\ci|.   clllicr   li\    illl'cil    cMi'll-mil    111    (lisca>c    In    ihc 

c(iril>  I  liciii-ch  cs  III-  liv  (ili.-l  iiicliiiii  In  aiMiHl  mil  iVmn  llic  presence  uf 
I  lie    ei'ou  I  h. 

Ah  iiilill  ral  mil   c\lcnil,-,   il\.-|iniea    lnllnw.-.    likcwiM^  ^jlamhilar  en 
iar;;'enielll  .        A     leu     nimilll.--     rmin     llie    ciillllliellceliieni     nl     llie    i||sea-e 
llleeial  mil    lie;:ins.    In    lie    rnllnweil.    in     lliail\     lll^-lailce-.    I  iV    lia'limlllia  je 
and     lliaikeil    cancernlls    cac|le\ia.       'I'lie    lirealll     liccii||ie>    fii'lKi    ami     llie 

ili.-charee  I'niil  ami  aluimlanl.  aeenm|iaiiieil   li\    nmie  m-  le-s  salualmn. 

I'ain,    Inn,    I-   alnm>I    i  ii\  analil  \     |ire-ciil.    nlieii    in    an    iiicrea   iIil; 

ralm,  .-Imniim;   up   In  ilie  ear>.  and   acin>>  the    pliar\n\.      1  tc'^liil  il  mii. 

Inn,    lieeiilile.-    pa  1 11 1  11 1    aild    dlllii  llli. 

Diag'llOSiS.        'I'n    aeenmplldl     llli.-    al     a.-    earl\      l    dale    a>    pns.-ilile    i.- 

iinpeial  i\  e.  I  .a  r\  iiLjnxnpic  cxaminal  mri  i.s  e.-seiit  lal  in  all  eases  in  dia^- 
imsis.  I'«y  llie  ii.-e  nf  llie  ilimal  miimr  ihe  ^mwlli  can  lie  seen,  lliiek- 
emd.  imdnlar,  ami  li\  pcra^mie  m  ihe  early  slaue-,  iilceraled  .md  en\- 
Cl'cd  Willi  I'll  lie  nil!  erii\\  I  ll>  la  I  er  nil.  'llie  lar\  n\  lieeniiles  dislnrled  and 
Idled  willi  fnlll  and  I'lelid  -ecrelmn,-.  wllicli  are  nl  lliem-el\e>  i^i  diai;- 
llnsl  ic    impnrlailee 

r>\  nplical  e\aiiiinalinn  alniie  a  diaeim.-i>  lielweeii  sai'cnma  and 
<'arciimma  eaniml  pn>iii\e|\  lie  mad".  i'mlialilN  in  carciimma  lliere 
iiia\'  lie  nmie  nlceralinii,  and  al  llie  same  time  le-s  rapid  i:rn«lh  than 
sarcdiiia:  Iml  I  licsc  are  nid\  iiial  lei>  nf  (leeree.  and  iipnii  miernsenpieal 
e\ainiiialmn  llie  diaL^imsi-  realK  depends.  I'ns-ilil\.  nf  llie  i  \\n,  -ai- 
ciiiiia   iiia\    lie  I  he  |e  .  pain  I  nl. 

Pl'O^'llOSlS.  \\  liere\er  i|  in;i\  lie  Inealed.  lancer  Is  niie  111'  llm  iim-t 
painful  a-  uell  as  nm-i  j'alal  nf  diseases,  ll-  nccnrreiiee  in  llie  lar\ii\ 
Is  tin  (Aceplinll  In  llie  i:e|leral  rille,  W'illmill  npelalmil  ihere  Is  lln 
Impe  w  liale\  er  ^\{  reen\er\ .      W  il  li  npeial  mil.  all  ImiiLili  llie  nmrlalil  \    is 

slill    \ei\    larije.  ea-es  lia\e   I ii    kimuii   til   ii\e   fnr  vear-   wiilmiil    any 

letnril  y''\  the  disease.  'I'lle  I  111  pnu  elllen  I  111  I  ech  ll  lij  ,ii>  which  is  imw 
piacliced  li\'  the  skill!', ll  nperatiif  i;ives  llie  palieiil  slill  iimri'  rea-nii 
fnr    linpe;     aiid    the    peieentaL'c   nl'    ieen\ene-.   alier   la r\  iiL!i'el nni \'    lias 

liecll    pelf.      Ilied,    IS    larger   , at     ihe    pre-eni     time    lliall    e\er    hefnle    in    Ihe 

hisldiv  y^'i  tills  di-l  ressiii:.:    inalaih,  alllmuidi  slill    it    is  small. 

Treatment.      'The  ipie-imn   y\{  relief   m   all   ca-es   is  an   impnrtaiil 

nlie.        I    lll'iirtllliatel\'    il    i-    the    llln-l    We   can    e\pei  t    In  aeennipllsll    ill    Ihc 

majdrily  y\\  cases.     I.ifi'  \\\.\\   he  prnlmmeil  and  made  nmie  cnml'nrtahlc. 


I   A  i;t   I  NOJI  A.        >  \  I'liiM  \. 


I  all 


-IIkI  lillcf  I'lnlM  |i,iin  ll-i'lf.  uhlili  l-iilli'li  ,l'_;i)|||/.ll|H,  -limiM  ;ll\\,l\-  lir 
.l^l\  III     if    ill    illl     |iii>-lli|r. 

A  I  li  r  w  ;i>liiii^  uiii  till-  I  lima  1  w  n  h  ,\  ('Iimh-iii'^  -|ii:i\ ,  I  lir  iiaiii  iiia\ 

III'  li'llrM'il  li\  1  liriiW  IIIL^  in  a  Ueak  -uillllull  III'  rnraill''.  Till,-'  nia\  1)1' 
liilliiWril    III    llki'    llianiliM'    li\'    a    >|ira\    nl     '      .      nr    '      .-jhT  i  rll!      -iilllllnll    .i|' 

|iiTiiiaiiL';iiiali'  of  |ii)la.-li.      Sniiu'  aiil  lim  il  n-   |inl'ir  ihr   iii-iilllal  imi  uf 

|iii\mIiI  III     inilnl,    ailSlnl.    nl'    |i  h  In  I  <  ijin.        .\ll\     n(    lili.-r     -IliillM     1 1 1  III  I II  l^l  I 

llii'  aiiMiiuil  III'  pliaryiiLiii  lai\  literal  I'li.vi-  and  lr--rii  ihr  i|  i-cliaiL;i'. 
'I  III'  nil  III  liiil,  iliviiml,  ami  raniplinr  iiiriil  linl  .-nhi!  inii-  aii'i'ail',  allmlcil 
III  li;ni    ihi'  aililil  i.iiial  rll'cil  uj'  iiiiilin'.;  ihr  iiillanii'il   !ai\ii\. 

Ill  iniiliiil  (lie  lar\ii:.:('al  pain,  wiiirli  i-  .il'lni  jhi'm  nl  in  an  iii- 
M'ra-iiiL'  laliu  a.-  (hi'  ilisi'a-r  aihaiins,  i-nraiiir  i~  |priilialil  \  ili.  Iir>| 
M'liii'ilv.  It  ran  ill'  I'liniini'iircil  l!\'  lliti'  al  nnii/.al  mn  nl'  a  I  m'  '.'  [iit- 
ii'nl.  -nliilKni,  lliiiiun  iiiiu  ijh'  tiiiiial,  L;iail;iall  \  iiiri'ra-iiiL'  lln'  |iri' 
<i'nl:iL'i'  (if  llii'  rnraiiH'  a-  tin'  !i'i|iiiriiiii'nl>  uf  ilir  .a-i'  iiia\  ilriiiaiiil. 
Winn  lir  kiiiiu-  llial  llir  i->iH'  \ull  iiii'\iialp|\  In'  l'al;il,  il  uuiilij  itiii 
I"  III'  Mil'  >nr:jiMiii  >  iliil\  In  rrinli'i'  ilir  mlhaiia-ia  a-  I'm'  Irnin  {laiii 
ami  a^  i  niiilnrlalili'  a-  i'ii'riiiii--iami'-   will   allnw 

W  lull'  ml  iilial  mn,  linni  I  lir  mil  iii.'  n|  I  In'  ili>i'aM'.  wniiM  lie  u  ImlJv 

n-rii"-,    I  iai'ili'ii|n|||\  .    Ii\     |il'i'\rlll  inu    im|li'Mi|inL'    -UlTniallnll.    will    -nlMi'- 

liincs   lir  III'   llii'   m'l'ali'^l    M'r\nr,    li  nul  iifiiiiiL;   mil    ihr   lil'r  n|'  llir   pa 
I  ii'i.'   al    li'a>l    I'll!'  mniil  li-. 

Iiinin\al  nl'  maliLMianl  urnwili  hv  i'MilnlarviiL':i'al  npi'ialmii  ha-  I'lr- 
•  piriilly  lii'cii  al  li'inplril.  Sn  lar  lln-  rrpml-  lia\r.  mi  lln  \\  hnir,  lie,  n 
r\>  ri'ilinijly  iin.-al  i-rar|ni'y.  'lln'  maii-,-!  in  a  prilnl  niri'  ilial  I  lia\i' 
^•'1  lar  M'i'ii  ii'pnrlril  i-  nm-  hy  Jura-,';,  n|'  llriilrlln'i'j,  Il  appraii'il  in 
I  III'  ■lniini'il  i>/'  l.'iri/iiiiiiliKii/,  Oi'lnlirr,  IM's,  In  I'li  I'lnlifi',  IS'.K,  hr 
i'i'niii\ril  rmin  ,i  wninaii.  a^^cil  II,  iiiiiIit  Imal  an.-n.-l  lir-ia  I  In'  ri;;lit 
\iiial  rnid  I'l'mii  llii'  anlri'mr  cninmi^surt'  In  ihc  pmci-.-^n-  vncah-;  alsn 
pai'l^  nf  llir  I.  I'l    \nial  nii'il  ami  aiili'rinr  rimimi.-in'i'  al  a  ilill'iTriil   sit- 

IlIlL''.         All     Wrl'i'     prn\ril     li\      III  irj'i  l.-rnpi.  a  I     iXalllinallnll     In     lie     all'i'ili'll 

N^illi  ipil  lii'lmma.     'I'Ih'  iii~I  rniin'iil    ii-rd   wa-  mii'  spn  iall\   i|i'\l~ii1   I'ni' 

I  III'   pnr|in<c.      A  I    I  III'  111 I'  willing'.   I  I'll    innlll  II,-   lalrr.   linn     hail    hrrli 

lln  rrliiin.  deal  rnial  iiirinlnaiir-  Inn!  rninir'i  in  llm  plan'  nl'  ihr  \nral 
<•ll^||^.  ami   llic  paliml    rniilil   -prak   Willi   a    Inar-i'   vniir. 

.Inia>/  is  III'  Mm  opiiiin'i  Mial  Inrah/nl  ranrrr  ni'  ihr  mnrr  lai'viix 
<aii  hr  rniiiiM'il  a-  I  liiii'nii;:hl\  hv  i'niln!ai\  m/ral  npi'ialmn  a-  h\'  lai'\ii- 
;ir(|nmv.  'I'lii-  npinmn,  Imwi'MT,  apprar-  In  hr  ha-nl  iipnn  Mir  niir 
Mici  r-^-inl    npi'I'al  inn 

\\  111  n  Mil'  caiirrr  hail  hmi  I'liiiliiinl  In  ihr  iiiiiri'  larviix.  ami  Im.s 


i 
i 

> 

'■■ 

Iv  ^j 

'■ 

MO 


DISKASHS    01'   TIIK    l.AKYNX. 


(•()iisc(|iuiitly  liccn  Ircr  Ironi  glandiiliU' coiiiplicatioii.  liiryngectoniy  lias, 
ill  a  iiiiiiilicr  (if  instaneos.  boon  succi'ssl'ul.  lVi']uii»s  the  most  rcinaik- 
ablc  cast",  as  it  was  tlic  first  of  its  kind,  was  tlie  ono  opcratod  on  oariy 
in  l«!»:i  1)}"  J.  Solis-C.'olicn.  Tt  was  a  c-asc  of  cpitholioina  of  the  larynx 
in  a  man  abont  40.  'I'lic  entire  larynx  was  removed,  and  the  severed 
trachea  was  stitched  to  the  skin,  thus  slintting  oil'  entirely  the  respira- 
tory ])assage  from  the  iiuuith.  After  recoAery  the  iinin  was  able  to 
articnlatc  in  a  loud  whisper.  It  was  supposed  that  the  air  taken  into 
the  pharynx  tilled  a  sort  of  pouch  in  the  low  r  part  of  it,  and  then  by 
miiseiilar  contraction  was  forced  through  the  tightened  fauciai  mus- 
cles in  imitation  of  the  vocal  cords.  Five  years  later  this  man  traveled 
over  America  and  Europe,  exhibiting  liini-cU'  before  the  various  ineil- 
ical  societies.  There  had  been  no  return  whatever  of  the  malignant 
disease. 

The  !Solis-('(dien  o|)eratioii  has  been  performed  a  number  of  times 
since  then.  The  last  case  lecoided  is  i)y  Depage  in  SociHe  Beige  de 
Cliiniriiiv,  -lanuary.  l.S!»8.  The  operation  was  ])erforiiied  eight  months 
previously.  .Ml  eoinniuiiicatifui  between  the  lungs  jiiid  mouth  was  cut 
otf,  the  trachea  l)eiiig  attached,  as  in  Solis-CohenV  ease,  to  the  skin. 
He  can  speak  in  a  whisiier  and  there  is  no  recurrence. 

Judications  are  beginning  to  .show  that  the  future  of  patients  suf- 
fering from  this  disease,  when  eonlined  to  the  inner  larynx,  is  not  ([uite 
so  dark  as  was  until  recently  believed,  liryson  Delavan,  in  a  recent 
issue  of  the  'f  hern  pen  lie  (latcltr.  speaks  squarely  upon  this  matter.  He 
believes  the  subject  should  ii'ceive  the  most  careful  eonsideratimi. 
Thrc^  groups  of  operations  are  olTered;  Thyrot(tmy  with  or  without 
pai'tial  laryngecloiiiy:  eomplete  laryngectomy  liy  the  Solis-Cohen 
operation:  and  complete  laryngectomy  in  cases  of  extensive  laryngeal 
disease  with  glandular  involvement. 

])elava]i  also  lays  down  rules  for  guidance  in  selecting  cases  for 
o])eratioii: — • 

I.  I'lvery  malignanl  growl  ii  of  the  larynx  o|  intrin.-ic  ori'iin. 
which  can  be  dealt  with,  should  be  treated  liy  an  operation  in  the  ab- 
sence cd' a  decided  indication  to  the  contrary;  and  the  operation  should 
lie  performed  with  the  least  possible  dcday. 

•J.  Every  tumor  of  the  larynx  >us]tected  to  lie  iiiiilignant,  of  in- 
trinsic origin,  of  limited  extent,  and  a)iparently  within  reach  of  free 
removal  Justifies  an  exploratory  ihyrotomy  in  a  suitalde  patient,  in 
the  absence  of  infiltration  k\'  the  -urroundiii'i  -Irnctures  and  id'  af- 
fection of  the  lymphatic  inlands. 


CAUCINOMA. 


AUfOMA. 


Ul 


3.  The  method  ol  o])eriUino'  as  pursued  b}'  JWitliii  and  Semuu  is 
recommended. 

in  the  ease  operated  upon  l)y  J.  Solis-Cohen  xhv  severed  end  (d' 
tlie  trachea  was  l)rouglit  to  the  external  edges  <iJ'  tlie  vertical  incision 
and  there  retained,  thus  cutting  olt'  communication  between  tbe 
pharynx  and  the  lungs.  The  advantages  oi'  tl  is  proci-durt'  are  very 
evident:  the  danger  from  inspiration  ])neumo;iia  is  greatly  lessened, 
swallowing  is  easily  accomi)lishcd,  the  power  of  [)hnnation  can  be  ac- 
quired (as  shown  in  the  cases  operated  on  in  this  manner),  and  tlu' 
patient's  comfort  is  gri'ally  increased,  as  the  weaiing  of  an  arlifieial 
larynx  is  not  necessary. 

Several  years  ago  a  method  of  treatment  nf  cam-er  was  devised  by 
Coley  which  seemed  to  1)0  ellicacious  in  eeHiiiii  cases  of  one  class  (d' 
the  malignant  disease,  namely:  sarcoma.  This  wa>  by  inoeidaiions  of 
erysi])elas  in  a  jialient  sulTering  from  ino]ier;il)h'  sarcoma.  Tlie  maliu'- 
]iant  tumor  would  j)artially  shrink  away,  and  remain  without  I'cgrowtli 
for  a  prolonged  ])eriod.  .\s  little  has  been  heard.  liowevtM-.  of  the 
further  advance  of  this  method  since  Coley"s  report  was  lii-st  issued,  it 
is  doubtful  whether  the  results  have  realized  the  e.vpeelalion^  of  the 
writer. 

I\Iiddlcmas  Hunt,  in  the  -lournal  of  JAirt/ni/oloii!/,  UhinohKjij.  niid 
OUilogij  for  October,  189S.  reports  an  exceedingly  interesting  case  of 
successful  operation  for  llic  removal  of  intrin,~ie  eaiicer.  the  chief  in- 
terest being  in  the  great  age  of  the  patient,  which  was  SO  year,-.  On 
exannnation  the  anterior  jiart  of  the  glof.is  was  fnund  to  lie  Idled  with 
a  pinkish-white  growth,  which  had  begun  to  break  dov\  ii  and  ulcerate. 
Jt  sprang  from  the  anterior  part  of  the  upper  surface  of  the  left  vocal 
cord. 

Owing  to  the  great  age  of  the  ])atient,  the  operation  was  divided 
into  two  stages:  the  first,  tracheotomy;  and,  live  days  later,  the  secnnd. 
thyrotomy,  removing  the  growths  and  surrounding  s(d't  parts. 

Although  attended  by  the  development  of  pneumonia  dining  the 
second  week  after  ojicration.  the  man  made  a  good  I'eeoveiv.  Xiic 
months  later  he  was  still  doing  well,  with  steady  iiuprovcnieid  of  the 
voice.  Microscopical  examination  verifieil  the  ca-e  to  be  one  of  e])i- 
thelioma. 


1 1 


I  UAiTKli  J.XXXll. 

FOHKKIN    liODIKS   IN    IIIK  LARYNX. 

l'"()Ui;iiiN  liodics  of  (Uic  I'dnii  (If  aiKitluM'  rr('(|U('iitIy  Iiccouk'  lud^id 
within  lilt'  lai'vii,L;<'iil  cavity.  'I'iiis  may  oi'dir  I'rdiii  tlic  I'dfcilili-  iii- 
.-jiiiat  idii  dl'  any  -iilislaiicc  that  may  iic  in  iIh'  mdntli  or  |iliurynx  ihii- 
\])i:  laui^hlcr.  nv  iVniii  cari'lessnos  in  tl.c  ad  of  ^wallitwinir  anil  in 
sniiic  cases  even  in  ordiiuii'v  inspifalion.  'I'lu'  names  'if  rorciiiii  Imdics 
that  Inivc  ohlaincd  an  oitrancc  into  tlic  hirynu'cal  ca\ily  ami  hidcjriMJ 
thci'c  are  legidii:  hfislles.  (Ish-jidnes,  needh's.  pins,  coins,  Iniltuns,  ])ai'- 
lial  plates  (d'  false  teeth,  ele..  as  deserilied  In  Roe's  eatalii,i:'iie,  have 
all  id'  them  iieen  extracted   I'l'mn  the  larynx,  and  some  of  them  ipiili! 


I''i,!,'.    I'i'i.       i  iinl  leiijalf   ill   ujiiltis.      lAnrr    l.riiiinx    HiDwiic.) 


fi'('([iiently.  Sometimes  the  iidroduclinn  id'  the  foreitrn  hidy  has  lieeii 
from  within.  i'"iir  instame,  liindiricoides  ha\e  found  thrir  way  into 
the  larynx  I'lMm  tlie  ii'xiphau'u^.  and  a  nnndier  (d'  installers  have  hecii 
recorded  which  emlfd  fatally,  [''oiid  has  also  hei  n  vomited  up.  to  lie 
thmun  liy  in.-pii'at imi  into  tin-  lai'ynx.  the  ■e-nll  hcimi  I'alal.  ('hil- 
dren  wlm  have  fnrmed  the  iiaiiit  id'  carryin'i  I'lii'eii^ii  liodics  in  their 
ninnihs  are  particularly  iiahle  to  the  aceid^nt.  Wdiile  ash'cp  the  nerv- 
ous sensiliilily  of  the  pharynx  and  hu  >n\  are  in  a  i|uiesceni  >taie.  and 
the  nhjiii  slips  into  the  larvux  withnut  warniiiL:.  Wniiieii.  who  rarry 
pins  and  nredles  in  their  nuiulh-.  are  liable,  diiriuL;'  the  acts  nf  ciumli- 
iii;^'  or  sMcc/'inLf,  In  snddtnlv  lintl  the  liltle  instniiiient  IndLi'i'il  in  the 
cavity  of  tlie  larynx,  l-'ii/s.  j.'if!  and  1)^7  re})resent  a  remarkahle  ease 
(■1!'.') 


FOHKKiN     liOlUKS. 


44a 


n'jH)i'ti'(.l  by  LfiiiKix  Jii'iiwiic.  Tlu,'  tuoth-])liitc  liiiil  rciuaint'd  in  posi- 
tidii  in  11k'  larynx  lor  two  years  and  ci^dit  monllis  willidiit  its  prcst'iicc 
bt'iii,ir  !>iis|)CC'lo<l,  I  111'  patient  Ix'inLT  under  tlie  inijjrt'Sssion  tliat  she  was 
sull'ei-ini;-  from  either  ti  herudosis  or  cancer.  'I'lie  jxisitioii  left  a  space 
for  hrealhiim  in  I'roiit  and  dso  lieliind  the  t'creiuni  liody.  l'"ii^.  13T 
exliiliils  ihc  lai'L^e  >ize  of  liu    phlte  after  its  ienioval. 

Symptomatology. — CmiuiiinLV  iri'ilation  more  or  less,  and  a  sense 
of  strantjuhilion  are  tlie  ordinary  syniplonis.  Tlioso  vary  in  decree 
and  chai'acter  aeeoi'dinL;-  to  tlie  size  and  form  of  the  foi'eiuii  hody. 
inodiiied  also  by  the  amouni  td'  nervous  excitability  possessed  by  the 
patient.  When  the  l)ody  is  lar,i:e  and  soft,  lilliicj-  up  tlie  larynx,  ini- 
niediate  snll'ocation  is  Wkvh  to  be  the  I'oult.  unles>  relief  can  be  at 
once  obtained.  Angular  bodies,  even  when  laruc  are  not  so  (Uii(  kly 
fatal,  as  respiration  to  a  eeriain  exieni  is  practicable  past  the  irrej^idar 


■11 

to 


I'i.ir.    \'U.      I'lMii  li  jilalr    niiiii\(((l.       lAilii     Liiiikix     liiow  iic  i 

side-;.  Iioiiub  bddies  are  likely  to  produce  intl.iniinai  ion.  Pointed  ones 
like  spiciila'  (d'  boiie,  needles,  etc..  while  tliey  do  not  int(  rfere  with 
resjn'ration,  on  the  sliulitest  motion  jirofhiee  pain,  and  from  Ibis  cause 
(d'tcii  render  dei;-|util ion  impossible. 

Diagnosis. — (,)uitc  freiiuciitly  this  may  be  positive  from  the  pcr- 
sfiiial  experience  of  the  patient,  lie  know>  the  nature  of  the  object, 
and  how  it  found  its  way  into  the  larynx.  'I'lii.-  can  be  \erilied  by  the 
use  (d'  the  laryn,i:oseope.  In  other  instances  the  larynud.-cope  alom  will 
have  to  he  depended  n[.on.  Sdnietimc-  in  children  neiiher  of  t'u'se 
met  bods  are  of  any  avail,  ixirstein's  autosi  ope.  when  it  can  be  a]i- 
plied,  should  reveal  the  condition  of  the  larynx  and  the  presence  of 
the  forei«i:n  body.  Digital  exploration,  also,  the  (iiiLrer  bein;i,'  passed 
candidly  into  the  larynx,  while  the  orpin  is  held  in  position  by  the 
fiiifjers  of  the  left  hand,  may  load  to  the  discovery  of  the  foreif;fn  body; 
bid,  when  tliis  is  of  a  metallic  character,  nothing'  will  reveal  its  form 


Is. 


•Ill 


i)isi:.\si:s  OK   Tin;   i.auv.w. 


1111(1  Idciiticiii  Ml  |i(isili\cly  a-  I'Xiiniiiiiitiim  liy  tlir  Kocnliitii   \-riivs.  so 
rcc'cnily  iiddcd  to  our  |i>t  of  inctliods  of  iiivcstifratioii. 

Prognosis. — 'I'lir  aciiilt'iital  ciitraiicc  (d'  a  foiTiizii  liodv  iiitd  the 
larviix  may  al\vay>  hr  cniisidcrcd  a  iiiatltT  of  xt'ioih  iiioinciit.     It  may 


i'"ig.    l:'iS.-    Liiryiigfiil    |mi1\  [iii-i'oiiciis,    .Mack('iizii'"s,   icxoh  iiig, 
willi   tliri'f  altacliiiii'iit;. 


])o8sil)ly  caiisi'  iniiiH'diatcly  a  fatal  roidl.  or  lead  t<p  it  hy  eoiitiiiiied 
(distniction  and  iiillainiiiatoi'y  action,  'riicrc  i.-  al.-o  in  many  iiisiancos 
lilt'  jiossibility  of  llic  liody  .-I'ttling  still  fartluT  down  into  tlio  nar- 


Fiir.  I'i'i.     l.io  \  ii;j('m1  |i()l\|iiis-f(iiccps.  WaxliiOiTs. 

rower  passaize  id'  the  trachea.  Still,  in  a  larij:e  niimher  of  instanees, 
when  the  hody  is  eompact  in  shape  and  without  projecting  angles,  it 
has  heen  eonghed  out  without  surgical  interference.  Sharply-angular 
l)odies  are  not  likely  to  he  expelled  by  NTatnre's  effort,  and  will  require 


r 


r       1 
i       I 


1 


s.  so 


iiiiiy 


I'orfKKiX    ItODiKs. 


•u; 


;:::;l^::i:::;t;-::r':;;;;l;::;::■-:;:;';,;;■;::^:- - 


! 


' 


■ 


I'-i^.   140.--   I.a,vn«..al  pulvpus-f,,...!.,   rnu.nk.rs,  cul .  in.  jau . 
into  iJ.e   hronH.u.!   .,,1,...  .......pletdv  olMn,..,in.   .vspinuinn   ui    tho 


Fij:.   141.-    )., 


'n-iio:Pal  pdlypus  foic.ps,  ^[a,k 


nidd 


I'll  C'.\ 


piratidu,  may  possibly  cxprl  it.     I 


upward,  ma3'  dislodge  a  heavy  body.    Forcible  cou-'i 
1'lieso  methods  failing,  laryngeal  (• 


•■nzH's,  aiticiilatod. 


levcrsiiig  the  patient,  heel.'- 


mirror  may  etlVct  a  renmvnl.    Of  in.trun...nts.  Maek 


iiig  may  also  aid. 
oreep,^  guided  by  tJie  tliroat- 


enzic'.s  Waxham's, 


l\ 


44G 


DISEASES   (»1-    rilH    I.AKVNX. 


I'Viifiikcr.s  (l""i<:s.  i:')S  1(1  111),  or  any  ntlicr  jjjood  form  inny  ho  used. 
.Soinctimos  a  snare  carefully  applied  would  lift  out  an  angular  body. 

When  the  ohjoet  is  below  the  vocal  cords  tracheotomy  may  be  rc- 
((uired,  and  in  cases  where  it  is  lodged  within  tlu;  larynx  it  can  l)e  best 
removed  through  tlie  tracheal  opening.  In  others  it  might  be  pressed 
up  through  llie  larynx  I'rom  tlie  trachea. 

"\ol  infre((uently  alter  tracheotomy  the  body,  if  located  below, 
may  l)e  expelled  througli  the  arlilieial  opening,  or  may  l)e  forced  up 
so  that  it  can  be  gras|)e(i  iind  removed.  Should  this  not  occur,  the; 
patient's  body  should  be  shaken  or  the  inverted  position  assumed,  witli 
tlu'  iio])o  of  bringiug  the  oll'ending  substance  within  reach  of  instru- 
mentation, if  it  be  impossil)le  at  the  time  oC  oj)eration  to  locate  the 
body,  tlie  edges  of  the  trachea  may  be  stitclied  to  tlie  integument  and 
the  wound  left  open  for  furl  her  search.  The  introduction  of  a  small 
uiirrfu-  may  assist  in  locating  tlie  ])ody.  Blowing  strongly  into  the 
trachea  may  assist  in  expulsion  by  tlie  reactionary  expiration,  or  the 
aiiilicial  ])rodiiction  of  cough  by  a  feallier  may  be  also  of  use  in  dis- 
lodgment."    (Kyle.) 


rJIAl'TKIi'  J.XXXIII. 


UOKX'KiKN    KAVS   IN   J.AHVNdKAI.  SIKCKKY, 


Tins  WHS  tlu'  til  Ir  nl'  a  iircliiiiiiinrv  nnic  liy  Joliii  Miiclntyrc.  iiKUi; 
tliiiM  two  years  ii^io,  upon  wluit  is  nckimw  Icdircd  now  to  ln'  a  very  ini- 
portaiil  siil)joct.  Tlic  (iiicstion  he  then  iiskcd — "Will  tlii>  imporliint 
discovery  of  tlic  lio('nltj:t'n  rays  l)c  of  u<{'  in  the  (Icpnrtniciil 
gol 


ol   liirvii- 


oirv 


has  hccn  answcrcil  over  iind  over 


liii  liv  ai 


nial 


I'l'SUl 


111 


the  alliiinative. 

Since  that  time  the  nielhod  id'  utiliziiii;-  the  Crookes  tuhi'>;  has 
heen  greatly  improved.  The  shadows  of  the  skeleton  of  tlie  living  hody 
can  be  so  clearly  delined  tiiat  every  hone  ean  l)e  distinguisiifd  in  |)6si- 


tion   from   the  siirroiindin';  softer  tissin 


Sill 


avs  of  liirht   nass 


through  even  the  osseous  frame-work,  so  that  any  imi)enetral)le  metallic 
siihstanee,  situated  in  the  nose,  larynx,  or  (esophagus  can  he  distinctly 
seen  by  the  x-rays. 

Still  further,  the  outlines  of  the  skeleton  can  he  so  clearly  de- 
lineated that  any  destruction  of  osseons  tissue  hy  malignant,  syphilitic, 
or  tuberculous  ulceration  can  also  he  discovered,  as  wdl  a-  fractures 
and  malposition  of  bojies  in  the  dilferent  ngions  of  the  body. 

Hence  it  can  readily  be  seen  that  the  discovery  (d'  the  I'oenlgen 
rays  was  no  light  addition  to  the  armamentaiiiiin  of  llie  tliroat-s[)e- 
cialist. 


Over  and  over  ai^ain  have  foreign  bodies  in  the  larvnx  and 


o'^onn- 


agus  been  located  by  the  sciagra])h,  thus  materially  facilitating  their 
removal.  One  remarkable  thing  is  the  clearness  with  which  thin  ob- 
jects, such  as  needles  and  pins,  can  be  di.'fined  while  completely  buried 


in 


the  soft  tissues  of  the  bodv, 


^J 


W'«    I 


n-tances  of  this  nature  wei-e  recentiv  reported  bv  A\'alker 


Down.e  in  a:'  October  issue  of  the  Jirillsh  Mnlintl  Journal. 

In  ilii'  f.rst,  D.  (J.,  aged  ID,  put  a  pin  in  his  mouth  while  a-leep. 
The  next  n'.orning  the  first  mouthful  of  breakfast  cau>ed  a  >harp.  lanc- 


ing pa 


in  in  the  tliroat  on  swallowinir.     This  was  followed  I 


ly  pain  on 


right  side  of  neck  close  to  the  thyroid  cartilage.     Careful  examination 
with  the  laryngoscope  revealed  nolhin-j:.    Two  months  later  a  satisfac- 

(147) 


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U(>i;nt(!i;\   it.ws  iv   i..\i[YNtii:.\i.  siioiKuv. 


t'Mv  liitcntl  \i('\\  of  ihc  |niits  \\ii>  olitiiiiifd  hv  a  Cmoko  tiilif,  ainl  llio 
|)in  (li.scovcri'd  in  In-  located  in  lln'  (•ciilrc  n{  the  tliyidid  cartila;.'*'. 
(  lilnrol'onii  was  adiiiiiii>Icr('d  and  llic  cartilajif  laid  liaic  in  the  iiuddk' 
liiif.  On  (lilting  llir(iii<:ii  tlic  |icri(liiindriiiin.  the  pnint  n\'  \hv  knilV' 
tiiuclicil  ttif  li('a<l  (d  the  pin.  I)nrin;r  tlic  two  ninntlis  wliiih  time  it 
had  liei'n  in  tlie  laivnx  the  pin  lia<l  niceiated  ihrunirh  the  (•artihi;:e. 
It  was  readily  e.xtraeted  and  proved  in  he  liciit  upon  itself. 

The  otliei'  ca.-e  neenrri'd  in  a  ^nrl  a.ii'ed  IS.  She  aeeidenlally 
(iiUfihed  with  a  pin  between  her  teeth.  As  a  result,  the  pin  i-lippod 
dnwn  her  throat.  She  thon<,dit  .-lu'  had  swallowed  it.  and  liir  sevenil 
days  thei'e  was  no  pain.  l''onr  day>  latei'  she  IuiikmI  sick  al'tci'  eating 
and  vomited.  While  in  the  act  she  leli  a  sharp  pain  in  the  I'i^ht  <ide 
of  the  tliroat.  close  to  the  thyroid  cartilai;e.  On  heini:  examined  witli 
the  laryn^'oscopc  nothing"'  whatever  conld  he  M'i'u  of  the  forei^rn  hody. 
.\  -cia;,M'aph.  hovTcver.  taken  at  once  rcvealcil  ii>  situation.  The  ni'Xt 
flay  the  laiynx  \\a-  ana-lheti/ed  with  cocaine.  an<l  cnrve(|  forceps  were 
pa.s.sed  lirndy  and  deeply  iido  the  hyoid  fossa.  'I'lic  head  of  the  jiin 
was  touched  and  Liraspcd  and  the  pin  was  withdrawn. 

.\  niimher  nf  instances  lia\e  also  heeii  recorded  in  which  sciairraphs 
liave  heeii  taken  (d'  loins  locateil  in  the  (eso|»ha,Lnis,  the  view  hy  the 
.x-ray-  hem;:  the  ^uiile  li\  which  successful  removal  was  accomplisliod. 


I 


niAI'TKIf   I.WXIW 
nl'KHATIoNS  KOR  NASAL  DKI-OKMlTl  |;s. 

WliKN   tliesc  (Rorniitii's  -.ul.v   fin,,,   in;illnrm;,ii,.n.  ,I..|,.rtivi.  .1.- 
N'l..l,im.nt,  or  pnt!i..|o^n,,,i  i,.,i„„  „,■  ,,„,   ,„,,,,.,,,,,   ^^^^^^,^  ^j^^^.  ^j^^^^^^^j 

rightly  he  consiili.ml  i,>  hclnn-i,,-  tu  tl,,.  \r'^\ihun\r  (ir|,|  „r' tl„,  ,hi- 
i<"ln-i>t.     W  hrn.  l„.«,.v..r.  tli.-y  o«.>  tlirir  nri-in  tn  vxu-nv.i\  injui  v  .,r 


Kil!.     Mli.        l..il.I     phlt,.     ,ur     |iil>Ml    ;l|cl 


I'i;:.    I  l.f.       sic.. I    J, ill    f.ii-    |ii,«;il    llMll^li     io    . 

.liM'i.M..  thry  wnuM  .,...,,,  ,„.uv  niitiiiallv  (o  \nUv^  f„  tl.,'  .ln„Kim  „f 
tile  irciHTiil  siinrcdii. 


It   is  of  1 


"■  l'"iiiirr  (hiss  that  thi-  ihniilrr 


of  that  unsi^'litly  (h'tnii„ity  (•o„iiii..nly  .iilhd  -suidl 
iU'iso  from  a  varioly  (.f  caiiscs.  hut  it  coi 


"'<'iii>.  iiii'l  |)iirti(iihiily 


'■-nose.      'ihi^  nuiv 


i>ists.  as  a  nih'.  (if 


of  \hv  l.rid.iTo.  owiiiir  io  the  dc- (ni.lidii  „f  the  cartihi,!: 


a  si II km;:  in 
inoiis  sept  mil. 
(II!M 


450 


Ol'KHATIONS    rou    NASAL    i)i;i'OU.M  IIIKS. 


Ill^ 


I- 1 


l'rof('s»ur  AiiiiaiKliilc  (lirilisli  Mcdiail  Jaiirndl,  Noveiiilicr.  IS'.tT) 
lias  tlirowii  out  sdiiio  valiialilf  sii<r<,'i'«tii)iis  lor  tin-  tiratiiK'Ht  of  this 
class  of  casus.  l"'ui'  lil'toi'ii  years  he  has  practicctl  wiiat  ho  (.-alls  "sliiiir- 
ing"'  of  tlic  (IcprosiMl  tissues  up  into  their  luitural  i)osition,  whether 
bony  or  otherwise. 

The  appliances  used  (•oiisist  )(:  1.  A  jjieee  t)f  sheet-h'ad  (Fig. 
1A2)  fornuMl  into  an  areh  with  a  ledge  on  each  side  to  rest  on  eaeh 
ehoei<.  The  areh  should  he  slightly  higher  than  the  nasal  bones  when 
in  their  normal  position.  On  eaeh  side  of  the  arch.  oj)posite  tlie  Itridgc 
of  the  nose,  a  slit  is  made  from  the  cheek-ledge  ii])  toward  the  siimmil 
of  the  arch.  ".'.  A  steel  [tin  (Fig.  J Ui)  about  live  centimetres  long  with 
a  point  at  one  end  and  a  cap  at  the  other — the  whole  central  part  iieing 
a  screw  with  a  nut  to  be  ap])lied  to  the  point. 

To  raise  the  depressed  bone  the  pin  is  jtassed  deeply  through  the 
nose  from  side  to  side  o])i)osite  the  bridge  or  more  dejires.'Jed  portion. 
The  nose  is  then  gi-ntly  lifted  up  by  means  of  the  pin.  and  the  leaden 
arch  slij)))ed  over  it,  tlu'  two  ends  projecting  out  through  the  notches. 
'I'he  nut  is  then  screwed  on  to  give  lateral  support  and  iirmness,  and 
silver  wire  pas:-e(|  in  lignre-(d'-eight  around  the  ends  of  the  needle  and 
over  the  iirdi.  to  ]iut  slight  traction  upon  the  raised  tissues.  A  cap  is 
also  fitted  ti>  the  needle-point  to  j)revenl  injury  1o  the  cheek.  The 
apparatus  reiniires  to  lie  carefully  watched  to  secure  good  results,  'i'he 
time  retjuired  for  ticatment  varies,  the  object  lieing  to  retain  llie  a|t- 
])aratns  until  the  lissiu>s  have  been  solidified  and  accustomed  to  their 
new  ]iositi()u.     Fig.  Ml  represents  the  apjiliance  iu  position. 

K.  ('.  Filet  (Mv  HI  jilt  is  Medical  Munllili/,  September.  18i)7)  reports 
i\  case  of  successful  treatment  of  .siddle-iuise  by  surgical  operation.  In 
his  ca.se  the  cartilaginous  se|)tum  had  beeu  destroyed  by  erysipelatous 
absces.s,  resulting  in  severe  de])ression  of  the  bridge. 

'J'he  operation  ))racticed  b)r  the  i'emo\al  of  the  deformity  {(in- 
sisted, first,  in  an  incision  twenty-five  millimetres  long,  down  the 
medial  line  of  the  nose,  extending  above  and  below  the  depression. 
The  tissues  were  then  dissected  back  freely  on  each  side.  After  cheek- 
ing the  hivmorrbage  with  hot  comijressos  an  oval  ]tlatinum  plate  was 
inserted  over  the  dejjressed  dorsum.  This  plate  had  an  area  of  twenty 
by  fifteen  millimetres,  was  curved  from  side  to  side  to  conform  to  the 
natural  shape  of  the  nose,  and  was  ])erforated  to  allow  of  more  perfect 
retention  and  fixation  during  the  process  of  healing.  Before  insertion 
the  plate  had  been  l)oiled  in  soda  solution,  was  preserved  in  alcohol, 
and  la-tly  immersed  in  bichloride  solution.     After  putting  the  plate 


>    1 

t 
1 

1 

i 

Ii 

t, 

sfitciT  ANKois  (>i'i:i{  \  rioNs. 


451 


in  phuT  thr  flaps  were  diawn  toirotli.T  and  siiiuiv.l  „v.r  it.  tli.'  wound 
being  d(.>cd  ascptically.  Al'liT  healiii.ir  tli."  \vli,.|..  nuso  was  s-.lid.  The 
tk'forniit.v  had  also  been  successfullv  niiidvrd. 

l{ot',  ui'  i{()clicster,  has  also  writH'ii  >nnic\vlial  extmsivdv  lately 

upon  ihe  -correelioj'  of  nasal  (hdnriniti.'s  by  snlxMitai ii>  oixTati.ui." 

and  the  following  is  ...i  abstra<t  o(  his  paper  (Hrlli.^h  M,;lintl  .Journal. 
November,  189T)  upon  th,-  sui.j...t.  irad  at  ihr  M,,nlnal  uw.xuv.  „|' 
the  associatiiin: — 


Kig.  Ht.—Xasal  ai-pliance  in  position.     iAittr  Aimaniialo. 


"Dr.  Koe  pointed  out  that  the  early  advaiita-..  „f  siilHuianeou^ 
operations  was  the  exelusion  ..f  air  from  the  w.miid.  therebv  av.)i.lin.' 
the  subsequent  inlla.nniation  that  followed  the  exposure  of  the  w.uind 
to  the  air,  but  that  at  the  present  time  the  only  advantage  of  perform- 
ing operations  subcutaneously  was  the  avoidanee  of  a  wound  nf  the 
skin  on  any  of  the  exposed  portions  of  th.'  body.  The  iniportanee  ..f 
correeting  nasal  deformities  on  aeeount  of  the  pmniin.'nce  ,d'  the  nose, 


45a 


ul'Kli Al  ln.\>    luK    .\.\>.\l,   l)i;i'nl(.Mrj|i;s. 


k 


I'  r' 

1 1 


in: 


u 


iiiid  tln'  (Miiisfiiuis  cITcct  of  siiili  (Icroniiitics  in  iiiducncing  tlu'  lial)iis, 
t li(iiii,flils.  iind  social  lil'c  nl'  a  ixm^-oii  were  then  pniiitcd  out.  ami  also 
tilt'  iiii|Mirtaii(t'  of  i-orri'ctiiiir  tlicsf  (Icfonnitii's  without  woiindiiiy  the 
skill,  so  as  to  Iciivc  as  few  ti'aci's  as  possihlc  of  the  ]ii'('\i(Mi>  disli^niic- 
iiiiiit.  Nasal  dcfoniiitics  were  usually  ili\id('d  into  two  inaiii  classes: 
idio|iathic,  or  coii>rciiital,  aiul  traumatic,  or  actiuircd:  luit,  from  the 
sur;:ical  staiid-poiiit,  l{oc  classilicd  them  into  the  deformities  which 
atVccted  the  hoiiy  portion  of  the  nose  and  tiie  (leformitie>  which  all'ected 
the  cartila,i:■inoll^  |iortioii. 

"1  >eformitics  of  the  lioiiy  |)orlioii  iiiiLiht  lie  suhdividcd  into  {)i) 
vertical — that  is.  those  which  distorteil  the  prolile,  in  which  the  dorsal 
lino  was  too  coiiv(>x  or  too  con<'ave;  and  (h)  lateral — that  is,  those 
which,  when  viewed  from  t'ae  front,  [iresentcd  unusual  deviations  from 
the  normal  contour,  wherehy  tlic  Iiouy  portion  mi^zht  lie  either  s])atu- 
latOfl  or  dellected. 

"heformities  of  the  cartilaginous  jiortion  uiiirht  ho  sulidividod 
into  (n)  those  which  alTcctcd  the  tip  of  th(!  nose,  whether  excessive  or 
defective  in  the  amount  of  tissue  or  distorted  from  its  normal  direc- 
tion, and  {b)  those  which  all'ected  the  winirs  of  the  nose,  which  might 
he  either  collapseil  or  almormally  expanded. 

"This  classilication  of  nasal  ileformities.  liowever.  did  not  a|)p!y 
to  or  iiu-lude  those  deformities  resulting  from  extensive  destruction  of 
the  hard  or  soft  parts  iiy  syphilis,  lupu,;,  or  other  diseases,  or  liy  acci- 
dents in  which  metallic  or  other  artificial  suj)porfs  or  jilastio  ojM'rations 
involving  the  integument  were  required  for  their  correction. 

"l{oc  then  descrihed  Ihe  dilVerent  deformities  as  they  were  found, 
and  the  oti(dogical  relations  which  they  sustained  to  local  causes  and 
various  systemic  conditions. 

"In  the  trealmeut  of  nasal  defoiinitii's  he  jiointed  out  that  the 
licaiity  of  the  nose  depcnde(l  almost  entirely  upon  its  symmetry,  so 
long  as  the  disproportionate  relation  helwccu  the  si/e  of  the  nose  and 
the  size  of  the  face  was  not  too  great:  therefore,  in  correcting  the  de- 
formities of  the  nose  it  was  necessary  to  study  the  symmetrical  rela- 
tions of  th(>  diil'eront  ])arts  of  the  nose  to  one  another,  rather  tliau  its 
]irop(M'tionate  relations  to  the  face,  lie  also  pointed  out  that,  owing 
to  llic  gi'cat  variety  of  causes  and  conditions  of  the  deformities  of  the 
nose,  the  ojtorations  ro(|uired  for  (he  c(U'rection  of  these  deformities 
must  ho  o(iual1y  varied. 

'■'Ihere  were,  howm'or.  geiu'ral  underlying  principles  governing 
the  dilTcront  operations  which  must  he  ohserved  in  order  to  aecotu- 


1^ 


sriu  r r AN  1:01  >  oi'kka iioss. 


•1:.;; 


\\\\>\\  till'  (l(sirc(l  i(>iilt.-.  'rim-,  ill  (■oiimk  vcrtitiil  (Irl'nriiiitios  of  the 
lidiiy  |i(prtiiiii  i>r  tilt'  HUM',  or  cxct  .-sivc  dcVfUtpnit'iit  nf  tlic  ti.-siic  of  the 
ti|»  of  tlif  noM'.  tlu'  r\cc-sivf  or  rcdiiiiihiiit  ti»iit'  iiiiist  he  rcinovi'd; 
wlicrciis,  in  \Uv  coiuavr  si-rliinl  (Icl'oriiiil v  of  tlic  Itony  iiortioti  of  tln' 
nose,  or  the  defect ivc  develo|iiiieiit  of  the  iiid  of  the  iio>e.  the  hoUow 
|iorlion  iiiiisl  lie  tilled  ill  with  tissue  taken  from  somr  ntlur  |iortioii  of 
the  nose  where  it  eoiild  he  spiired,  and  the  elevated  portions  rrdiieed, 
so  iis  to  make  the  iio-e  symmetrieal.  In  the  ease  <d"  injiirv  to  tlu'  Tiose, 
in  wliieli  there  was  displaeeinent  rather  than  destiiution  of  the  tis- 
sues, the  operation  eoii>isted  in  plaiinj:  the  tis>nes  in  tlieir  ori>:inal 
po.-itioii.  or  so  adapting  them  as  to  render  the  contour  ^^i  the  nose  sym- 
metrical. In  cM'iy  instance,  however,  the  operation  was  to  he  per- 
formed .".iihciitam'oii.-ly  from  the  interior  of  the  nose. 

"The  writer  then  deserihed  a  nuniher  of  cases,  illuslratinix  the 
I  luiner  in  which  the  various  operations  were  perfornie(l.  and  exhihited 
enlarired  photo^irapliie  illustrations  of  ]iatient>  Itefore  and  after  oj)era- 
tions.  lie  also  stated  that  there  were  three  conditions  vlii<  h  must  he 
ohserxcd  in  order  to  insure  success  in  these  operations: — 

"1.  The  first  was  tlioroufrli  antiseptic  precautions,  for,  if  suppura- 
tion in  the  wound  should  take  place.  in;.;rafted  tis-iies  Wdiild  hi'  de- 
stroye<l.  and  not  oiilv  tiie  oiijecf  of  the  tiperation  lie  defeated,  hut  the 
ileforniity  of  the  nose   wduld   lie  iiicrea-ed  thereby. 

•■'v'.  In  the  next  place,  the  plan  of  the  operation  mii-t  he  cand'ully 
studied,  in  order  that  all  the  ti»ues  at  disjjosal  mi.iiht  lie  utilized  to 
'.he  hest  advanta^'e. 

'■."».  In  the  third  place,  ureal  care  and  atti'iuioii.  >ulise(|Ueni  lo 
operation,  were  as  important  as  the  operation  itM'lf.  for.  110  matter  how 
well  directed  the  operation  iiiii:ht  lie.  the  ohject  couhl  not  he  attained 
unless  scrii|inlous  atteidiim  was  jiaid  to  the  liealin;:  process.  The  |iarts 
must  not  only  he  held  in  place  hy  retentive  appliniU'cs,  hut  the  shape 
of  these  ajipliances  and  the  drcs-inir  must  often  he  chaniiod  from  day 
to  day,  as  the  swelliiii:'  siili>ided  and  the  niiioii  of  tlu'  parts  took  ))lnce. 

"|-"re(pienliy  the  principal  or  miiin  operation  mii-t  he  siipple- 
mcjited  hy  minor  operations  for  the  correction  of  sliirht  defects.  An 
unduly  prominent  portion  inidit  reipiire  lowcrinir  and  a  <1epressed  part 
raisin*;,  and  so  on  until  the  work  was  completed." 


i 


1 1        :-i 


M 


I! 


!   ii 


if 


i'j^ 


CIIAI'TKU  LXXXV. 


OI'KltATlONS   RUl  Cl.KlT   I'AI.A'I'I-:. 


It  is  widrlv  comcciIimI  tluit  ti|M'rations  for  clcrt  piilntf  iiro  iiiad- 
visal)le  hoforc  tin.'  iiid  til'  llic  x-cond  vcnr.  I'iist  operations  should  l»t' 
|irrroriiie<I,  if  possible,  alpoiit  that  period,  and  secondarv  oporatioiis  hy 
tilt'  fourth  or  lilth  vciir  wlicu  iifcfssarv.  .Still  furtlKT,  linal  operations 
upon  the  hard  palate,  oi'  to  eoiiijiletelv  close  opening's  still  left  in  tlio 
Boft  pahite,  should  al\\ay>  he  done  hv  the  trutJi  ur  twelfth  Year  at  the 
latest,  .\fter  this  age.  the  availai)le  ti^^ues  are  too  seanty,  and  the  |)0S- 
sihility  of  inijiroviuf.'  the  voice  loo  limited,  to  render  operation  justi- 
liahle.  and  the  most  that  can  he  (h)ne  is  in  the  way  of  li.xation  <d'  oh- 
tnrators,  to  overcome  to  some  extent  the  nattiral  del'ormity. 

Careful  ohservations  made  hy  many  experienced  surgeons  have 
also  hrought  out  a  nuiiilpcr  (d'  important  facts,  uhic  li  help  as  irnides 
in  the  treatment  of  this  defect  in  (h'velopnieiit.  Wln'n  there  is  hare- 
lip logelhcr  with  cleft  palate  it  is  advi^ahle.  according:  to  sume  autliori- 
tics,  to  operate  vu  the  lip  even  in  early  infancy,  in  urder  to  insure 
eilicieid  nnrsinfT,  while  the  oj)eration  in  the  palati'  is  deferred  lo  a 
later  date.  The  chief  oiijection  to  surgical  inli'rferenee  with  the  hard 
or  soft  palate  during  the  first  two  years  of  hi'e  is  the  extreme  delicacy 
of  the  tissues  alVeeted.  with  their  liahility  to  teai'  upon  the  slightest 
traction. 

Tlio  liealthier  and  iielter  tempcre<l  the  child,  the  les?;  voracious 
I  he  api)etite:  and.  the  smaller  the  chd't.  the  earlier  may  the  operation 
he  performed. 

Th(>  higher  the  vault  of  the  hard  palatt'.  the  more  likely  is  the 
operation  to  ho  successful,  as  there  is  a  l)ctter  suj)ply  of  soft  tissu(^  from 
whidi  to  constriu't  tlie  necessary  Haps. 

The  longer  the  ])alate,  also,  from  hefore  haekward,  tlie  more  ho])e- 
fid  th.e  prognosis  after  treatment,  as  the  traction  toward  the  centre 
has  always  a  tendency  to  shorten  the  antero-postorior  diameter  of  the 
palate. 

In  reply  tt>  anxious  friends  who  are  naturally  alarmed  at  the  dif- 
(leulty  in  nursing  produced  hy  the  presence  of  cleft  palate,  they  can 

(ir.i) 


STAl'IlYI-OHHIlArHY. 


4:>5 


be  asfiiind  tliiit  tliie  can  bo  aceoniiiiij-litd  icaiiily  l)y  tbe  use  of  n  iiiii.-- 
ing-l)()ttli'  willi  ii  Imij,^  iii|i|ilc  witli  tin-  tiju'iiinir  "H  the  lower  sidf  ni- 
with  a  projtctini,'  lljip  «m  iho  ii|ii(rr  nin-.  I'.y  inittiiiii  t-ilhtT  nf  tlii'>i' 
well  into  tlu'  iiiotith,  the  t)|K'niii<:  iii  tlic  |iiilatc  will,  tn  a  laiL't'  t-xtfiit. 
be  closed,  'i'lic  chiltl  can  thus,  hy  liciii;;  better  iibie  to  swalioM,  attain 
the  strength  an<l  ajrc  necessary  i'nr  succesr>ful  treatment. 

Sta|)liyl<irrlia|thy  i>  the  name  .i,i|ilieil  tn  operatinji  lur  the  i  h)>uii' 
of  the  clel't  in  the  solt  palati'.  This  is  an  oM  (»|>erali<»n.  an<l  has  lie(  ii 
|)eriornie(l  lor  more  than  a  century.  There  are  many  inetiioils  by  whii  ii 
it  may  l»e  done.  I'erhaps  the  simplest  is  the  one  ;.'eiierally  adopted  and 
described  so  clearly  by  .1.  \V.  .MacDonald  in  hi>  work  upon  "SiiruKal 
l)ia^'no.«is  ami  Treatment."  I,si»,s.  'J'hc  position  he  chooses  i.-  lor  the 
pati»'nt  to  lie  on  a  hii:h  talde  with  the  bead  turned  to  the  rijrhl  ."-ide. 
-o  that  the  blood  will  not  ;rravilate  into  the  pharynx  Clinrchili's 
position  would  sctin  to  be  superior  to  thi>.  lie  places  th>'  patient  upon 
his  back  with  the  head  at  riirht  aiiiile-.  to  the  s.pine,  hapi,'ini:  over  iIm' 
end  of  the  table  and  .-u|»ported  by  an  assistant.  In  tlii-  po.-ition  tin' 
blood  will  drain  into  the  iia<o-pliaiyn\  an<l  conid  readily  be  -ipoiiL;!  d 
away. 

The  sta;res  of  the  operation  are  tin'  follitwin;::  — 

].  .\fter  ana'stheti/.inji  with  chlorob>rm  or  .\.  ('.  V. .  a  iiioiith-<j;a.u: 
is  in.serted  ami  the  throat  i.'^  reiidereil  as  aseptic  as  possiide.  The  end 
of  one  side  of  the  cleft  is  then  held  ten<e  by  a  tenaculum  foicep^  and 
a  narrow  strip  cut  oil'  from  the  ed^re  of  tbe  deft,  from  the  free  marLnn 
lo  the  aiiirlt'.  This  may  be  done  by  a  thin-bladed  knife  m-  a  «baip.  nar- 
row, aniiular  scissors.  In  tbi-  preparatory  staire  both  sides  are  treal(d 
alike,  the  object  beiiiLT  to  make  char-cut.  raw  edi.'rs  throULilioiit. 

'i.  The  sutures  may  be  (d'  .-iUci'  wire,  ehromicized  catu'nt.  or  >ilk. 
tile  last  nientioiied  beiiii.;'  as  j^ood  a>  any.  Ot  needle-;.  allhoULdi  many 
kimis  are  used,  the  liMlf-ciirve  llaL'edorn  in  a  iHidle-bolder  i^  ircnm- 
metided  by  Mac  Donahl  a-  i,re!ierally  applicable.  Tb.'  Ili-i  in  idle  -linuld 
lie  in.-erteil  about  (i  millinieircs  from  the  iiiar;rin  on  .iin-  -idr  an>l  aliuut 
I'.'  niillimetre-  fi'im  (lie  an.Lde.  and  parsed  din-etly  throu,i:li  that  pni-- 
tion  of  the  velum.  It  should  then  bi'  reinsert<-d  from  behind  forward 
on  the  other  siile  of  the  cleft  at  similar  distance.-,  thf  -ilk  thread  caie- 
fnlly  drawn  throiii:b  by  means  of  forceps,  and  the  needle  withdrawn. 
<  >ther  needles  .-hould  be -imilaiiy  plai«'d  at  distance-,  .if  about  TJ  milli- 
metres in  a  similar  way  until  the  posterior  end  of  the  cleft  is  reached. 

3.  If  the  cleft  can  now  be  closed  without  too  much  tension  the 
sntiires  mav  at  once  be  carefnllv  tied  and  the  thread-;  cut  nlT     Tf.  iiow- 


•I.'.d 


on  l;  \  I  ln\-     I  Hi;    (I  1,1  I     I-  \|.  \  IK. 


m; 


I  ' 

;■    ! 

\  ■■'." 

iiiiP 

' 

.iii' 

^    IlBil 

: 

»'| 

k 

VWr,   llic  .-Uillll    1«    li'M    ::l(ill.    lllf    IiII-cM-    |iilliltl    lllll-clr-.    imi-t    lir    i  lll    lir- 

foro  closiii},'  the  (Id  I.     Till-  ciiii  lie  ilniic  liy  inn  kin;,'  nii  iiici-inn  miu  ihc 
Sdl't    |i!iliil('  iiiiiiirdiiili  Iv    iiitiriiiil   to  the   liiiiiiiihii'   |iriir('->  iiml   iiiii 

ll|)\Viinl    until    the    IIHIm  l(>    air    X'M'IiiI.       'I'llis   slioujll    ll<'    ilnllc    cili    III 
side.  iUnI    then    tllr  -IIIIIIO  llniWII    tniii'lJltT  iiml    tlrd.      'I'lli-r   -llolllil    II 


IM; 


I'll 


he  I'rliiiiM'd   iiii 


til  tl 


IC     M'VClllll     or     ClLlilt  ll     llil\  , 


'rill'(ill;.'ll>>lll    tile    <i|M'lil|  mil    llir    IiIitiI  Mli:    -ll<i|||i|    lie    riinlrnjlnl    liv 
cjllct'lll    |pn'>>lll('    ll|iiill    llir    iilicdllli:   -put.-    Witll    .-lllilll    idcdLTi't.-   ot'   llllll- 

scptic  iilit^ftrlifiit  ({ittnii.  (  iiic  liiiiiu  liikni  lu  ;i\<iid  iill  wniii'tcs-iny  dis- 


Inrliiiiu*'  id'  I  he  niw  -in  liu 
lid  I 


Will  11    lllr    n|irrilt  inn    ]>    iiXtT   till'    |i;llt.- 

I  III 


sliDiild  lie  li^ditly  dueled  uilli  iiidiiliinn  mid  ihr  inci-inii  piiintrd  with 
iddnf'onni/.t'd  collddion. 

Uranoplasty.-  'I'hc  nimc  diiliiuli  iiml  .-(■iinii>  npcriitutn  nf  rlii>iii;;' 
fis>iiif  (d'  till'  liiiid  piiliitc  is  iisiiiilly  |u'rri>rnit'd  al'icr  Sir  Williiiiii  l-cr- 
^Mis.'^nnV  |iliiii.  r"ii>t  the  cdifc-  id'  tin-  clt'l't  slionld  he  piircd  ii-  in  the 
ii]K'r;itinn  I'nr  sl;i|di\  l('rrli;i|iliy.  Tin' >ulnn's  also  iuMTlcd,  i>iit  ji't'l  un- 
tied iinil  held  iisidc  liy  an  assistant.  Then  midway  hctwccn  tlir  dfl't 
and  the  i:!\t'iilnr  nini'Liin  an  iiici-inii  i-  inadi'  dnwii  In  the  Imni'.  the 
incision  heinj:  of  ('t|iiai  Ifiiirth  willi  the  clcrt  in  ihr  liiird  |»alat('.  Tiit» 
lionc  is  iircriilly  cut   throimli   with   tlic  ihisci  and    I'orccd   over 

toward  ■  ,sial  line     The  siitiiit'>  arc  tlim  lied  and  tlic  lateral  in- 

cisions packed  witll  lodol'oini  ;;an/.c. 

ir  the  iipcratimi  i>  >ni(e-sliil,  the  lis-nies  close  up  liy  new  Ipuiie- 
rorinatioii.  and  a  coniplete  hard  palate  is  evcntiially  lornicd. 

MaMin  Warren,  of  lio-ton.  was  anion;;  the  iirsi  to  i-losc  the  hard 
palate  without  cutting  the  lione.  His  plan  was  to  detach  tla|i-  of  eniii- 
lii)icd  |K'riost('Uin  and  iniicoiis  nicnihiaiie  from  tiie  hard  palate  hy  means 
of  a  pcriioleal  elevator,  taking:  care  not  to  tear  the  arteries  of  the  ante- 
rior and  po.-lerior  palat  iiie  canals.  The  soft  jiidale  was  also  separated  on 
each  side  frmii  the  horizontal  plates  i>\'  the  two  palatc-liones.  IJefore 
tyiii^'  the  suture^,  eiits  were  made,  if  n'i|uired.  midway  lietween  the 
lissiirc  and  the  alveolar  margin  on  eaeli  ^ide, 

'I'lie   after-treatment    in   all    operations    is   an    important    malter. 


WM 


antiseptic  irrigation  is  always  needed,     ll   i-  lietter  al^-o  to  apply 


the.  iodofoinii/cd   collodion    no   inatler   what    o|)eralion    is   perfoinied. 
The  food  should  he  of  Iliiid  form  for  a  iiiiinher  of  davs  and  the  sutures 


if 


.should  never  he  ri'inoved   in.-idc  ol  a  week.      1  he  hands  of  the  (  hih 
wlicn  necessary  sliould  he  coni rolled,  and  a  careful  watch  niaintainod, 
until  all  daii.iifr  of  injury  to  the  tissues  he  over. 

Will  n  i-olatcd  -lints  fail  tn  uiiiic.  ihcv  inav  sometimes  he  encoiir- 


I  II  \Miri,  \>i  V 


457 


jii^cil  to  cliiM-  li\  y;riiMiilal  mil.  llic  |iiiit-  In  iii:^  Imic  hnl  li\  niinili'  nf 
>il\tr  or  sin;i«'(|  Itv  jriilviiiiiMiiiitriv. 

Willi  till'  tilijcct  of  iiii|iro\iim  \Mi<('-|»ro<Iu(lioM  nl  n-  curly  iin  iii;*' 
il-;  I  HI.-.- 1 1  ill'.  r>|o|i|iy.  of  ('|iirii;ro.  Iins  riMciil  Iv  ilcvisrtl  iiliij  |iril(t  it<  i| 
MU'Ci'>>|ii||\  il  sprciiil  incllioil  of  tri'litlin'lil  wliicll  lir  roiisidcrs  ;i|i|t|l- 
(lllllf   rVlll    III    fillly    ilirniuy.       I'>V    ll    lie  I  l.lllll>    tlllll    t'lc    IMII«(I(".    lll-lrinl 

oT  I  If  I  111:  II I  low  (I  I  Id  ill  ro|i|iy.  lire  il('Vt'|o|ic(l  linin  t  he  lii-I.  iiinl  I  In'  iiii>;il 

lolll'   rilllMll    liV    lIlC    |iri'SCll(C   o|'    tllf   clcl't    is    llcMT    lorilinl. 

A  Iter  \  ivil'yiii;:  tlic  I  i.-.-iics  ol'  llw  Milt  di'll  I  if  triiii'  t  lif  lioiiy  fili,'f  s 
of  tllf  hiiiil  fiffl.  tliii>  fiivoiiiiir  tlifir  union  uhfn  liroiiirlit  into  fon- 
tiift.  'I'lifii  lif  |iiis.-f-  ji  (loiiiilf  >il\fr  uiif  -iiliiif  lliroii'^li  lln  |iiililtiil 
|ir(Kf>s  of  tllf  |iiil;itf-liolif  iiliil  iiliollifr  |Iiio||h1i  tlif  |iiil;il;il  |i|offS-  of 
tilt'  !»ii|ii'rior  iii:i\illiii\ .  'I  lll^  i-  ijoiif  Mil  fUf ll  sjilf ,  Lfixl  liiilioii>  iiiiKJr 
to  suit  tllf  |iiiit<  iiml  |ifrfoi;itf(|  for  tlic  wires  fiif  llifii  |iliiffil  in  |tosi- 
tioii.  oiif  on  fiifli  siilf.  iinil  the  \virf>  nrf  |iii>.»fil  tliroii::li  ilnin.  'I'o 
;i|i|ir(i\iiiialf  the  liony  clfft.  tlif  ii;:lit  iiihI  li'fl  wiif-  lifiirf>l  llif  ;i|if\ 
jii'f  t\vi.-tf(l  loLiftlifr.  |iiiltiii::  lfn>ioii  ii|ioii  the  |iiirl'.  liif  Miiiif  to  lie 
ilmif  with   tllf  iiiilfiio!'  jiiiir.      If  r-iilVif  If  III    tfii^ioii  liiii   lif  «iiffl\    |iiit 

ll|ioll    tllflll    to    illilW    tllf    two    >iv|fS    of    tllf    fiffi     lo^ftllfl'.    IIlfl>|o||>    will 

not  lif  nfffssjiiv.  If  iioi.  ilifii  llif  liiinl  imlfitf  on  fiuli  side  liftwccii 
tllf  fifft  iiml  tllf  jilvfohir  i-  to  lif  lui  -iiiic  iiiiinfou-|\ ,  tlm-  jillowiiij^ 
of  {,'!'( 'iitcr  If  lis  ion.  'I'lif  I  III  I  tons  ciin  l  In- n  lif  ilr.iw  n  c  lo.-c  r  toLictlif  r  liv 
t wist iiij:  tllf  wirf  >iit iircs  iiiid  lifM  in  |iosiiioii  until  union  takf-  |iliiff. 
Tilt'  purls  should  now  lif  tlioroii;rlily  drifd.  and  wlifiif\fr  nfff>saiy 
liiU'  siitiii'fs  lif  |iiit   in  to  liriii;:  tlif  tissiifs  into  |ifi'ffft  a|i|iositioii. 

('oiii|ilftf  fontrol  of  tllf  fliild   i.~  always  rft|nirfd    for  .-onif  days 

after  o|ifratioii.      .\iitisf|itif  trfatiiifiit    of  tlif   i ith   >li(iiild   al-o  lif 

attfiidfd  to  and  only  .-oft.  Ii(|iiid  food  adniinislf red. 

.\s  tllf  opfiativf  tifatiiifiit  |iraftif(M|  hy  j'ldniiind  (>ufii.  and  ile- 
>erilif<l  liy  liini  al  tlic  la>t  annual  iiifftin^rof  the  I'liiiisli  .Mfdifal  .\sso- 
eialioii.  diil'fi'.-  sonifwliat  from  any  of  the  fo!-f;.ioiiii:  iiiftliod>.  and  sus- 
tains sonif  |ioiiit.-  that  are  new,  ihi-  (  ha|itf|-  will  lie  (  lo-ed  with  a  lirief 
description  of  the  ihrcf  staircs  which  he  dfliiien: — 

1.  Iicfore  operation,  ll  is  iinperalive  that  the  child  -hoiild  hi; 
]iiit  in  a  LTood  >tate  of  health  The  chronic  dys|icp>ia  from  which  many 
children  liaviii;;  clefl  palate  siiU'cr  >lioiild  he  removed.  l'"or  I  his.  tin-  ad- 
iiiinistratioii  of  a  rliiiharh-and-so  !a  mi.Miirc  is  an  excellent  tliiiii,'.  .\ll 
carious  teeth  should  he  removed  or  <  lcane<l  ami  lilicd.  .\deiioids  and 
cnhirfrcd  tonsils,  if  present,  should  also  he  taken  away  licfoie  opcratiiijr 
upon  the  cleft,  and  the  parts  '/\\vu  time  to  heal. 


45H 


OI'KIIATIONS    Foil    (  I.Kll     I'M. A  IK. 


!     ij 


'.'.  npcriitinii.  lie  \isri*  n  r.iii(li(i((l  Smitli  ^ra''  nrnvtl  witli  stotit 
siiikcs.  wliii  li  lit  into  llic  crcvict's  ol'  the  ti-ctli  ov  into  tlii'  >,Mmis,  as  he 
siiys  "liiirml('>s|\ ."  Init  iiisiiriii;;  ii;:iiins(  nn.v  slippinjr  (if  tin-  iiislru- 
iiK'iit  iliiriiiL:  lln'  ii|it  riilinii.     Tlie  iiiiii'stlictic  need  is  tlilororonn. 

Allcr  iiiiii'stlH-Hi)!  is  prodiiicfl  ii  >trnii!,'  -iitmc  i-  pa<s('i|  tlirini;fl) 
the  tip  (if  tlic  (oiiiriii .  ami  tlir  niLraii  <lrawii  well  forwanl  licrmi'  IIh- 
vajr  i^i  iliMTtcd.  'I'lic  (  liihl  i>  thru  lirnn;.'lit  In  tin'  nid  nl"  tlic  tahlc  with 
the  head  liani;iim  Dvcr  to  kcrp  the  h!  mk!  out  <d'  the  larynx,  iiuuh  as  in 

(   hlllrlilirs    pii>lti<i|l. 

Allrr  dcmidiii;:  llif  cd^ri's  of  tlir  cleft  a-  in  the  nrdiiiarv  niflliod 
lir  niako  a  Ion;.'  incision  on  the  inner  side  (d"  each  alveolar  pnx-ess. 
'I'hese  incisions  arc  nsnally  very  fre«',  traversin','  lli»'  attachment  (d  tin; 
levator  and  tensor  palati  muscles  as  well  as  the  pala(o-pliaryn;,'eus. 
'I'Ih  II  the  rnspat(U'y  is  intridiiccd  am'  the  miico-periosteal  thips  are 
raised.  The  attachment  also  id*  tin  .ipom'iirosis  of  the  velum  to  tin; 
posterior  liorder  of  the  hard  I'.-.iate  is  divided  with  curved  scissors.  As 
these  incisions  produce  a  ^'ood  deal  of  lia'inorrhaiie,  this  is  cheeked  hy 
lirm  pressure  with  sponires  hel'ore  the  sutures  are  inserted. 

(•wen  pilfers  silver-wire  sutures  to  any  others,  lie  uses  a  modi- 
I'lcatioii  (d'  Smith's  needle,  and  when  the  citd't  is  complete  ti'U  or  twelve 
sutures  may  reijuire  to  he  inserted. 

One  important  ])o'  it  that  he  insi.-ts  upon  is  that  there  should  he 
no  tension  whatever  ujion  the  Haps.  The  incisions  at  the  sides,  al- 
thou^rh  alinort  as  wide  as  the  orij^inal  deft,  usually  heal  without  dif- 
licnlty. 

'!.  .\fter  operali«>n.  .\s  anaesthesia  passes  idl".  Hie  child  may  vomit, 
hut  unless  this  is  very  ])rolonj;ed  it  will  not  interfere  in  any  way  with 
the  sutures.  In  order  to  favor  mouth-drainaire,  the  child  should  ho  so 
pla.  cd  upon  the  pillow  that  the  blood  will  (low  out  upon  alisorbont 
cotton  arranged  for  tlu'  purpose. 

Tiio  hest  food  to  jjive  is  liome-nnide  heef-jelly,  as  it  slips  down 
vvithont  elfort. 

.\s  soon  as  possihle  after  operation  the  child  may  he  taken  out  of 
lied,  and  even  out  of  the  house,  to  secure  tlie  benefit  of  inhalin.i,'  the 
pure,  fresh  air. 

Washinir  the  month  with  solution  of  lioric  acid  or  other  antiseptic 
should  not  he  insisted  on,  nnless  the  child  itself  is  willing,  as  the  struij- 
<rle  of  opposition  could  do  more  harm  than  tlie  vvasliin<j  would  do  fjood. 

If  septic  infection  takes  place  we  must  await  the  result.  The 
wcmnd  may  bo  opened  by  staphylococcic  invasion;    but  after  a  time, 


I'HANOPLASTY. 


i:.!» 


with  proper  cnrc.  the  fovor  will  siil)si(l(>,  mikI  the  sunderc]  aii-l  swollni 
('<1kos  of  111.'  ficft  will  look  l)ri;,'lit  mid  cli-iiri  apiiii.  and  tlim  tli,.  up<Ma- 
(inii  may  In-  ropoafcd,  tlioii^'h  in  n  minor  d.-uMc.-.  and  with  <  vcrv  ]m>U- 
ahility  of  bcin;;  successful. 

Dr.  Owen  i.s  of  tli(>  oj)inion  that,  while  imthinu  i>  so  prejudicial  t(. 
pn.nipt  union  after  staphvinrrhapliy  as  septic  itifeetion.  vil.  havin-r 
onee  rceovered  from  the  septicirmia.  a  complete  imiminity  is  for  a  time 
anpiired  as  a  result,  and  further  operation  may  he  at  once  performed 
with  the  prospcvt  of  a  jrood  iiiiinii. 


SMfi 

1. 1* 

I 


li  i 


llli  i^ 


i  til 

Mi 


INDl.X   TO   Ll'IKIfAKV    l!i:i"i:i{KN(  KS. 


.\lil>.>tt.  711, 

AlKiciiiiiiliic.  -'.'•!. 
Alniiliiiiii.   114. 
Aili'iiot.   I:i7. 
Ali'xiiiidii'.   174. 
AmiiiiKiiilc.  4.")(>, 
Apiicit.   KM. 
.\rcli;iiiiti:uilt.    lOil. 
.\r:i<.l(l.  -Jli^. 
.\s(li.    KMi. 

Hnlicr.  r.(i.   111. 

I'.ahrs.    111. 

liiikfr.   sj. 

I'.iilliii.L'cr.  s:t. 

IJiinctt.  -IW,. 

Hciilc.  rlilV.inl.  :i!N. 

r,i'll(!ii|.    ItiS. 

i!cil,'t'm;i  ii'i.  4Ui. 

Uill'.rnl'li.   110,   1-JS. 

lUikctt.  rM. 

HislHip.  :«),  ■■).'•.  :!><.  '■'!•  '■'•"'■  !'*•  '"•■ 

1(11,  'l\:i.  24.").  4t'-2. 
Klackli'V.  !ir.. 
UlaU.'.    12:i. 
Uoiict.   104. 
Hostock,  !i:i. 
Hoswmth.    IS.  \i\.   :'.o.   :;s.   41.   44, 

02,  7').  s:;.  Sit.  '.10.  01,  o.'i,  1 12. 

nit.  122.  124.  i;!s.  141.  i.vt.  lo"), 

1711.  lit*.  10.').  21s.  22!t.  2:!7,  2.')r),  : 

2S(i,  .'ill.  ;i.">s.  :!o.'j.  ;j'.t;!,  401.  4:17. 
Huviii.  no. 

l!(.\\liiv.  20'). 

Uiiuiii'.  :!0.  04.  0."). 

hri'sfri'ii,   14S, 

Urtipliy.  4r)7. 

15ro\vii,  MoiciHi,  107. 

lirowiir,    l.fiiiin\,    :i.".,    .")7,   ■")'•',    04. 

120.  12.!.  141.  lis.  150,  174.   1O2. 

2i:i.  2Si'..  200.  ;i!t(t.  402,  41t7.  412. 

4:!4.  4'.7.  44:{. 
Hii'iis.    !2.'). 
linisrhk.'.  104. 

lint  111-.   II'). 

lUills.  211. 

('atKHii>it\.  130. 

r;ii)art.   22:{.   22;'). 

Cartel-.  'M. 

("ai-v.  ;!."):(. 

(•aHs.'ll)c-irv.  83,  124,  130,  245.  .307. 


00. 


00. 
1 1  .■). 

100. 
270. 


102. 
•201 1. 
414. 


10:!,  tia,  111 


(  lia|iiil.-.    lit:;. 

t  halclliir,   10.'). 

(  hfval.  s;!.   10(1.    i(;7.  307. 

(  liiaii.  lU.  4.-)S. 

(  liiiiiliill.  4.").">.  l.">-^. 

(  lark,  111. 

(   ilHlllct.    1  14. 

(  oakli'.v.    137. 

(  dIk'Ii.  4.  Solis  . 

Colcv,   441. 

(  oliii.   270.   2S(t. 

(oilier.  00.  7.'),  SI,  211. 

(■()()])er.  170. 

Conieil.   140. 

(  DMriiioiit ,  310. 

Col  ilade.  301. 

(  rodkes.  447,  44,S. 

(  intiss.   llolOniiik.  S3.   ISd. 

1  taiiiasriiiiio.  270. 

Itailiiellii.  3S7.  3SS. 

Davidson.  02. 

l)e  llloi.s,  2.")."). 

|)el)ioiisr<es.  30(1. 

I)e  la  Sola.  :iO().  414. 

Itelavail.    I'.fvsoii.   .")7.  04.  01,    IJ2.    1.34, 

101,  -200.   211.  22s,  440. 
I  teliuicliow  ski.   1('5, 
llellioe,  141. 
jlcsault.   170. 
I  !<■  Siiiioiii,  204. 
Ilevassc,  l;")!, 
lleville,   151. 
lloOell,  .3S. 
|lolltrele|i(iilt,    1511 
llowiiie.  Waikci-,    H7, 
Drake.  '!" 
Drcyfib      447. 
I  )ii]iaj,'c,  310. 

i;iiet.  ;•:.  r..  4.50. 

I'.iiclisin.   1  15. 

1m'1-{X11soii.  Sir   \\ '..    I5(), 

Ferrard.  310. 

l-'lalaii.   141. 

l-'latean.  ISIt. 

Kox.  lliit-rsloii.   104. 

Fraenk(d.  41.  50,  02.   150,  U'),  .35(;. 

FveiK-li.  02. 

Kniideiiltial,   140. 

Friedliiiider.  M). 

(-H51) 


•n;-j 


IM>r,X    TO    MTKItAHV    HKKKUKNCKS. 


iidi.   III), 
ivcl.  IC.it. 
If,  2!t:i. 
.■Iinndt,  .?!«). 

.kIv.    i:ili. 

il)l.'.  .1.  S..  'JIU. 

Icji^im.   li'T. 

leit-^iiNimi.   ITS,  :2t)H.  214.  ln.'i. 

liick.   11(1. 

<>M-l>'iii.   lit. 

osscliii,  l.^■i. 

oltsl(  in.  CiO.  (11.  21).  .'tS'l. 

<m;:u('iiliciiii,   1(!S. 

rani.  Dniulii^.  r.fi,  I  )S.  Ids.  l(;;i.  170. 

liiiiuaUI.  ;")?.   1  IH,   ITS. 

iiilt.   i:iT. 


Il.ill.  (Ic  liiivilland.  2()<>, 
Hall.  .Maisliiill.  42;}. 


Ilaj 


!(;>, 


isl. 


lliiiiscn.  410.  411. 

Harrison.  ITO. 

Ilaton,  141. 

UcIot.  55. 

Ilrndlcv.  11(1. 

Ilcrynfr.  Kill.  2"!),  29(1.  3(54.  3S0. 

IlcwlcK.    H.-?. 

llilairo.  1(15. 

Hill,  110.  143. 

His,  101. 

Ilodonpyl.  134. 

Hopkins,  141. 

Ildpniann,  12(>. 

Home,  .IdW'pli,  128,  234. 

Hunt,  Middlcnias,  71,  302,  441. 

Hiinfcr,  424. 

Injrals,  Mctchrr,  83.  102,  107.  177.  225. 
3!>7. 

Jackson.  Hnslilinfis  ,  423. 

.Fnrvis.  54,  7(1.  122. 

.Ifansoliuo.  410. 

.I(Mil,  04.   104. 

.lohnson,     ■^4. 

.fdni's,  f'arniault,  28,  5(5. 

doiivdain.  100. 

Jiillion,  303. 

Jurasz,  431). 

Knnthack,  102. 

Krllv.  l?ro\vii.  1.34. 

Kirstoin.  345,  34(1,  347,  340.  3(58,  443. 

Klol)."*.  300. 

KniRht,  ('.  11.,  131,  174,  IflO,  402.  430. 

Koch.  300. 

K rails.'.  170.  205,  402. 


Kriiuli'in.  315. 
Kvic,  S3,   14S, 


:!(M5.  31 


l.aliovv.  114. 

Lake. '7 1.  83.  8S.  J  Id,  404. 

I.aincros.  .'17  I . 

I.an;ri',  \'ict(ir.  s7, 

I.anrcns,  4 in. 

I.I  dcrniaiin.  s7. 

l.cllVits.  134.  Iiid. 

I.cllaivc.  04. 

I.cI.mk!.  245. 

Lcrnidxc/.,   IfiO. 

I-.vi.  :i7l.  374. 

I.iaias.  371 . 

l.incdln.  225. 

l.iiKlcniiinn.  212. 

Lodcr,    104. 

I.ojraii.  220. 

l.ouciilicri.'.  .50.  214,  3H4. 

l.owndcs.  1 12. 

l-UfT'il.  27s. 

l.uniiij,',  ."i'.i;!. 

I.nsclika.   101.  203. 

MacDdnald.  ( iicvill.-.   1(18, 
Ma.l)<inald.  .(.  \V.,  455. 


2(17 


4(7. 

lliinfcr.  434.  435. 

.1.  \dland,  50,  04,  100,  115. 


41.  74.  122, 


Maclnix  re. 
Mackcn/if. 
Maikcnzii', 

175,  420. 
Mackenzie,  Sir  Moroll,  17 

2.M.  311.  412.  410.  423. 
Mciiridc,  110.  12(1,  205. 
Mafiiiani.  .310. 
^fajdi-,  3;id,  307. 
Maisli,  110. 
Martin.  21(1. 
Mathicu.  2(17,  2(18. 
Mayer,  40tl. 
Ari'iizcs.  31(1. 

Mover.  Wilholni,  204.  208,  211. 
Mioliel,  125. 
Miekulic/.  31(1. 
:^Iilli,i,'an,  1(18,  170. 
Moldenliaiir,   Id5. 
!Mdrier,   171. 
]\Idnnt  lilcver,  410. 
M<inn\   no.  10(1.  417. 
Ahilliall.  «7.  (!8. 
^hirdoeli.   70. 
Murray.  20(5.  402. 
My  lea.' 8(1.   17(i,  170,  181. 

Xavratil.  410. 
Neisse,  14(5. 
Neweonibo,  210,  307. 
Xvk's,  1(55. 


INDEX    TO    I.ITKHAKY    HKFKKKNCKS. 


•U)3 


O'Dwvpr.  350,  351,  353,  254. 
Otto,  20!). 
Owen,  457,  459. 

Pakfs,  247. 
Paterson,  191. 
rattcrsoii,  230. 
Pawlouskv,  140,  150. 
Pt'an,  140." 
Poglcr,  127. 
Poiiiiewaii.  33. 
Poiahpt,  233. 
Piimio.se.  9,  79. 
Pivor,  374. 
Pynclion.  207,  2()2,  271. 

Kailtoii.  434. 
Kedus,  234. 
Keed,  ]4(i. 

Reeve.  H.  A.,  218,  220. 
Kfid,  24<i. 
Keidcl.  143. 
Riehaidson.  280. 
Robertson,  171,  321. 
Robinson,  IJeverlv,  105. 
Roe,  25,  70,  289,  451,  452. 
Roentgen,  447,  448. 
RooHa.  185. 
Rosenberg,  181.  392. 
Rosenniiiller,  31. 
Ros8,  G.  F.,  428. 
Roy,  119. 

Sacli,  143. 

Saint-llilaire,  l(i5. 

Sajons,  38,  (i2,  04,  100,  154. 

Sandfoid,  211. 

Sappy,  437. 

8chedi,  122. 

Schep])e}i;rell,  115,  403. 

Schiil'er,  71.  1()5. 

Schubert,  281. 

Sehiilier,  14(J. 

SeluiKze.  11. 

Seller.  fiO.   125,   130. 

Senioii,  Sir  Felix.   194,    120. 

Sendziak.  272. 

Shurlv,  18,  54,  59,  GO,  04,  102.  122,  140. 

Siebenniann,  280,  281. 

Sicthoir,  218. 


Sikkel,  128. 
Simonowsky,  402. 
Sinilii,  lui.stjicc,  425. 
Sok(d<)\vski,  272. 
Soniers,  2;{3. 

Spieer,  Scaiies.    I  14.   171. 
St(i,.nk.  391). 
Sto'.-.er,    131. 
Straifjlit,  l!<-\viird.  103. 
Kwain.   117,  119,   i;M. 
Synionds,   143. 
Syne.   141. 

Tavlor,    Frederic,  424. 

Tiroiii:<oM,  St.  (lair,  I(t3,   1.J3.   143. 

Thorner.  .Max,   141,  221,  3(i2.  345,  ;M9, 

353,  374. 
Tiartis,  374. 
Toeiilitz.  279. 
Torn wa hit.  203. 
Trendeleniinrir.  70. 
Trehilian,  140,  148. 
Tyrrell,  Shawe,  'M). 

V'elpeau,  240. 
X'erneuil,   120,   141. 
Volkmann,  147. 
Voltolini,   125. 

Wajriier.   14.  41,   103,   194.  279. 
Walton.  29;). 
Ward.   120. 
Warren,  450. 

Watson,  .\rthur.  S(i,  134.   1  13. 
Webster.  200. 
Weiriiselbuuni.   14:i,   1.".9. 
Weil,  221. 
Williams.  143. 
Willif;k,   143. 
Williston,  1 14. 
Wiiiirrave.  Wvatt.  58,  01. 
Wishart,  r3.  i55. 
Woakes,  119.   17.'). 
Wolfenden,  272,  274. 
Wrijihl,   .lonaliian,   !12,    1  l.").    ll'.t.    175, 
211. 

^■^arsh'y,  234. 

Zeim,  70,  81,   170. 

/uckcrkaiiill,  13,  74,  70.  119,  105, 


(iK\i;i{.\L  INDKX. 


SkcIKiN     I.    -DiSKASKS    OK    TIIK    VosK. 


m 


M 

if!  I 


Acccssorv  cdvilics.  iUiiUuniy  nl.  7. 

(Iis('iis<'-i  of.  l.")!l. 
Acute   sinusitis.    I.")!>. 

('ti(iliif,'\.   I.">'.>. 

syinptiiniatoldijy,   ItiO. 

tri'iitmcnt,  Uil. 
Adciioiiiii  <if  tlic  nasiil  passiifrc^.  l.'ij 
.Aiiiitoniy  of  tlio  <'.\t('inal  nose.  .'{. 

acccssorv  siiiuscs.  7. 

ct  iimoid  cells,  7. 

frontal  sinus,  ti. 

niaxillaiy  sinns.  S. 

nasal    fossa'.  .'!.  4. 

septum.  4.  ' 

sphenoid  sinus.  7. 

tiirliinateil  liones,  .'>. 
Anjfionia  of  the  |ia-i>aj.'es.  rt2. 

treatment.   I. '{.'{. 
Anosmia,  1(14. 
Antrum,  cyst   of.   174. 
.\ntiiim  of  llijjtlimore.  8. 
Ajjiosexia,  121. 
Asthma,  lellex,   120. 
Atro|iliic  rhinitis,  5S. 

l!ell()e(]"s     cannula     in     nasal     lia'Uior 

riiajre.   lOS. 
I51aekh'y"s  invest i^^'at ions.  0"). 
Hlood-vessels  of  tlie  nose.   11. 
Hone,  superior  turhinated.  ."i. 

middle  turliinaled.  ">. 

inferior  t uriiinated.  (1. 

Carcinoma  of  the  nasal   ]ias-.a;.'es.    141. 
dia^fnosis.  142. 
eti(do^'y.  141. 
patholojry,    141. 
jirofinosis.   142. 
sNtnptomatolofrv.  141. 


treatment. 

11   of 


Momlrom 


!'■ 


(hronie    disease    of   antrum    of    Hi", 
more.   1(!2. 
diajinosis.  Ititl. 

e\   'oratory  puncture.   lilT. 
ti      silluinatioii.    Iti.S. 
etiolofT.v.  1  (!."). 
iiat  hoi 


"srv, 


102. 
irotrnosis,  l()!t. 


svuiptomatJilojiv.    Hi.'i. 
'(ICI) 


(hronie   disease    of   antrum    of    Hi;;li- 
niore.  treat  irieiit.   Mi!), 
coinliincd  operation,  171. 
direct  irri<,'at ion,  Kii). 
opcnin;;  of  inferior  mealirs.  1(10, 
I7(". 
alveolus.   170. 
canine  fossa.  170. 
Colunniar  cartilafie.  distortion   of,   S!i, 
!l(t. 
jierforatioiis  of,  !tl. 
f'onjj;enital  syphilis,   l.">."i. 
(  ysi   of  the  antrum.   174. 
Cystoma  ot  the  nose,  l:{ I. 

Dex'ialions  of  nasal  scjitum.  74. 
Disease  of  the  frontal  sinus,    ISl. 
Disease  of  the  splienoid  sinus.  ISO. 
l)is"ases  of  the  accessory  sinuses,   l.V.t. 
Diseases  of  the  elhinnid  cells,  175. 

iliajinosis.   177. 

etiolo^'V.    170. 

palliolo<ry.    17."). 

pro^'uosis.  177. 

s\niptomatol(p;ry.   177. 

ti'eatment.   17S. 

Klcctr<icautery     puncture     in      hyper- 
trophic rhinitis.  ,").'). 
Kleclrolysis  in  septal  dcfornn'.y,  S4. 
Ispislaxis,    10(i. 

diairnosis,    1(17. 

ctiolo-iy,    KHi. 

patholojiy.   lOO. 

profrntisis.   107. 

syin)pl(niiatolo;,'y,   10(1. 

treatment.  107. 
I'lthmoid  cells,  7. 
disease  of.    17."). 

Piliroma  of  the  nasal  passages,   12S. 
diagnosis.   120. 


•tiol( 


128. 


pathology,  128. 
]ild;;nosis,    120. 
svmptomatoloftv.  128. 
treatment.   120." 
Foreiifii  bodies  in  the  nose,   112. 


di 


lU 


sym])tomatolof;y,   1 12. 
treatment.   ll.'J, 


<ii:\i:i;vi,   imii;\. 


It;.-, 


Km 


IIIU  lllii^i-.    Ml."). 


<ial\iiii(ujuilci  V  li:ill<  r\-.  ,).'!. 
fihiMdcrs,    lis.' 
<iliin(ls  .if  the  iiiKc.    II. 
' inK^tciii'^  jiliii:-,  <il. 
liiiiinMild'^  (i|M'iii1i(iii.  .">7. 

Ilii.v   fcvci'.  (ir  \ii^.iiiii,|.,r  ihiniii-.  ;i:;. 

iliiifjnosis,  iis. 

•  Iiiriilioii  (if,  !I7.  !)s. 

'I  i(i|<i</y,  !I4. 

;.'iiijria|iliiinl  area.  !IM. 

|iatlKil(i<ry.  !i;i. 

IK'iiodiciiy   (if.  !17. 

|ii('\cnti\c  iiicasiiic-;.  !»S. 

|ii(if;ii(isi>^.  !)S. 

'<yiii|itoiiia((il(i<.'\ ,  !»(;. 

trcalinciit.  !i!l. 

(•<(tisli)iiii()ii;il    ticatniciit.    <t!l. 
ticatiiiciit  (if  nasal  jiassatrcs.   |(in. 
If.vdnurlid'a.  nasal,    l(i;{. 
Ny|i<T(i(i|,|iic  rhinitis.  ■).-). 


Fnncivalion   nf  (lie  n(isc,    I  j. 
In-tninicnts   nscil    in   ncisc  mt, 
I.-.. 

•  icclric    ]iliii1ii|i|i(ini'.    I."). 

laryn^dscdpc,   17. 

nasal   s]i('cnla.   IS. 

liowdcr-lilowcis.   24. 

saws,  etc.,  ^'t. 

snares,  etc..  27. 

s|i(ikcslia\ cs.  ,.((...  -js. 

I.acnnial  canal.  7. 
I.M|ins  of  tlic  ndsc.   14(1. 

(liafrnosis,    147. 

(•(idldiry.    14(1. 

Jiatlldldory.    14(1. 
|iro<rndsis.  147. 
s.\in|itdniatdldjrv.   14(1. 


Ii  II  lilt . 


tri'alniciif.   147 


Mas 
-Mcnlli 


saf'c    m 


liliii-    iliiiiiljs.    Cil. 


Kil  III  diseases  dt  jid.;,.  ;,,|,i  tin-dill 
35. 


Xasal  lidncs,  :). 
Xnsal  (Icfdniiiti 


Xasal  liydrdiiliii'a.   lo:!. 
Xasal  iidlypi.   1  HI. 

dia;;ndsis.    121. 

<'tidld;iry,   1  IS. 

|iatll(lld<ry.     11(1. 

|ii(ii,''ii(isis.   121. 
rcllcN    distnrlianics. 
sex.    Il!». 


I's.  djicralidii-.   fur.  44!t. 


120. 


.Na-il   |iii|\|ii.  .\iii|,| alii|d;.'y.   1  1!». 

Inatiiicnt.   122. 

Iiy  clfcliiily^is.   12.'>. 

Iiy   fiirci'iis.    12."i. 

Iiy  snares.   122.   12.'!. 
\a~al   septiiiii.  defininil  ies.  74. 
dia^Midsis,   SI. 
etidldi_fy.    7.">. 
|iiii;,'lid>is.  S2. 
-ei|nehe    allel'    dpeial  inn.    S7. 

-yiiiptdni:iidliij^-\ .   SI. 
Ireatiiienl.   s;!. 
elec1riily~is.    SI. 
ineflidds   Iiy    I'.dsudrtli,  s;i 
nietlidds    Iiy    (iissellierry,    H4. 
Illellidds    |,y    (  iiili»s.    K.'i. 
nieihdds   liy    In^'als.  S;!. 
luellidds    liy    Kyle,    8:t. 
nietlidds  liy   Lake.  S8. 
inetlidds  liy   Wafsdii.  SC). 
riililier   >plint~.   ss. 
sihci-  inlies,  s."i. 
Nasal  sepiiini.  defdiiniiies  of.  74. 
ediidiliini^   in   actual   life.  7,5. 
-kiills  df  aliiii  i</ines.  74. 
df  civilized   races.  74. 
Ndse   in   plidiiatidii.    12. 
Ndsc  in  rcspiratidii.  |;{. 

Olfactdiy  area   (if  the  nose.   12. 
Operiitidiis  f(ir  nasal  defdrniitios.  44!). 

.Xnnandale's  inethdd.  4r)0. 

Kllet's  met!     1    4.5(t. 

Roe's  nietiidd.  451. 
Osteoma   nf  the   nose.    |:?(;. 

etidldfry.    1.^7. 

pat  lidldj.'y.    i;)7. 

syniptdniatdl(i<.'y.    |;{7. 

treatniciil.   I.')7. 


I'apilldnia   nf  the  iids 

tic.ilnienl.    12(i. 
Parasites,  iiasul.    |  |:!. 


12(1 


-yillpttillial(il(i;;y.    1  1  t. 

"exas  sereww dill 


14. 


'I 

tieatnienf.  1 1."). 
rani'inia.    l(l."i. 

I'll\  ^idliij.;y    nf    nn-e    ;iud     Uri-t" 
IMI^c-.    12. 

iiii-c    ill    phiiiuil  inn,    12. 

in   respiiiitinn.   1:1, 
-elise  (if  -nicli.    12. 


Tdsti 


ernir  ihiiid^cdpic  iina''e,  ;{(l. 


::i. 


site  (if  attnehnii'iit.   120. 


Iiinitis.  acute 
diauiidsis 
eliiildo-y,  ;[^ 
pathdldiry.  ;!2 
liriifriidsis,  ;}.■{. 


^l' 


ict; 


<.i:m:kai,  indkx. 


m 


■■■'  s 


'..  m 


lit 

-  q;r 

i;    : 

Rliinilis,  acute.  ])ri(i)livlii\i-.  .!.■;. 

syiii|ilniiiiit<il(i;>y,    ."{.'1. 

Ircatiiiciil,   .'{4. 
Khinitis,  alniitliic,  r>8. 

Uiii^'iiiisis,  (il. 

I'liolofiy,   ')!!. 

]in  thole  Iffy.  TiS. 

])r()f^ii()sis,  (iii. 

sym|it<)matol(]<ry,   (io. 

troatiiH-nt.  (i2. 

l)y  (iottstciii's  ]>lii.£!^,  04. 
l)y  inassajjc,  (14. 
Kliiuitis,  clironii-,  '.\~. 

diagnosis,  IW. 

ctiolofiy,  r!7. 

patliology,  .'57. 

lirof^nosis,  .'{8. 

syni|(loiiialoIojifv,  37. 

troaliiifiit,  .^8.  ' 
inassafic  ;{!(. 
Rhinitis  fihiinosu.  70. 

casps  by   I?rnn  .Murdocli.  70. 

rasps  by  ^liddlcnins  Hunt,  71. 

casps  by  ]{i(hard  Lako,  71. 

cases  by  SeliilTpr.  71. 
Khinitis,  hypprtrophic,  45. 

dififjnosis,   ">(). 

etiolofjy.  47. 

])atholojiy,  4."). 

profrnosis,  51. 

syni|)toinatolo{ify,  40. 

treat niput,  51. 

by  electrolysis.  55. 
by  turbinectoniy,  5ti. 
Ehinitis,  nMlematosa,  07. 

treatment.  (18. 
lihinitis  jiurulentia  of  children,  41 

diaffiiosis,  42. 

etiology,  42. 

pathology,  41. 

prognosis.  43. 

syni])toinatolotry,   42. 

treat nipiit.    l:!. 
lUiinoliths.   110. 
<liagnosis,   111. 
])rognosis.  111. 
symptomatology,    1 10. 
Irpnimciit.  111. 
Jlhino.acleronia,   140. 
troatment.  140. 


Sarcoma  of  the  nasal  passugi's,   VXA. 
diagnosis.  l.'tO. 
etiology.  i;{8. 
jiathology,   l;t8. 
]n'ogno>is.  i:!!i. 
symptomatology.  130. 
treatment.  1.30." 
.Sense  of  -imcll,    12. 
Sensitive  areas,  04. 
Se])tum.  anatomy,  3. 
abscess  of.  02. 
bilateral  tumor-;  of.   127. 
jK-rforation  of.  !tl. 
treatment  of,  IM. 
ulceration  of.  }I2. 
Sinus,  frontal.  7. 
nia.xillary.  8. 
s])henoid.  C 
Soft  palate.   13. 
.Syphilis,    151. 
diagnosis,  153. 
])athology.    152. 
])rognosis.  154. 
sym])tomatol((gy,  152. 
]>rimary,   152. 
secondary,  152, 
tertiary,  152. 
treatment.  154. 
Syphilis,  congenital.    155. 
diagnosis.  155. 
etiology,    155. 
])atllology.    155. 
])rognosi>^.  15(). 
symptomat(d(igy,    155 
treatment.    15(i. 

'I'uberculosis  of  nasal  passages,  143. 

diagno>is.  144. 

etiology.   144. 

])athology.  143. 

jirognosis.   144. 

symptomatology.  144. 

treatment.  145. 
Turbimited  bones,  anatomy  of,  5. 
Turbinectomy.  5(i. 

Vasomotor  rhinitis,  03. 
N'omer,  4. 

Zeim's  exppriment<  on  aninuils,  76. 


lifit 


Skciion    II.    -1)isi;.\si:s  ok  tiik   V 


Abscess  of  the  post-pharynx,  258. 

tonsils,  244. 
Actinomycosis,  300. 
Acute  bulbar  paralysis,  320. 
Acute     infectious     phlegmon     of 
jiliarynx,  2(U. 


til 


llAliVNX. 
J3l. 


.Vcnte   jjliaryngitis. 
diagnosis,  233. 
etiologv,  231. 
pathology,  231, 
prognosis,  233. 
symptomatology 


232 


<;k\ki{al  indicx. 


467 


A<ul('  |iliiuviif,'iti>.  Inaliiiciil.  SM. 

Acute  tonsillitis.  24."). 

Adenoid  1,'rnwtlw  in  nii-((>  |)liaryn\,  u'04. 

diiifrnosis,  210. 

etidjdfry,  2llti. 

patliolnn-y^  204. 

]ir<if.'n()sis,  210. 

W,\MI|)t(iniJlt<ll(m\  ,     207. 

f.'enenil  syniii'toMis.  20s. 
treatiiicnt.  211. 

'i|ieratiiin   l)y  eiuclle,  214. 
fdrccps,  21  I. 
fralvanncantery.    21:?. 
Adcnnma  of  the  iialale'.  2il|. 
Ad\isal.ili|y     ,,|     j;,.,„.ni!     aiui'st  liesJM 

212. 
Anie.'.lliesia   of  iiliaiyn.x.  212. 
Ana  slhetic.-,  elidiee  "df,  212. 
I  Iddrotdini,  21:!. 
ether.   212. 
ethyl  l)rdniide.   21.'!. 
nitrous  o.xide.  21.'!. 
Anatomy  of  pliaivn.x,   l.s.l. 
iirteries.   1!)0, ' 
faucial   tonsils.   |!i|. 
linpual  tonsils,  l!)2. 
ni'i\es,  1!»0. 

<>|K'nin<,'s  into  pliarviix.  is:.. 
pharyngeal  fjlands,'  I'tO. 
pharyn-real   tonsil,   ]!(0. 
Aprwsexia,  20!t. 

Beniffn  tumors  of  pliarvn.v,  2!tO. 
dermoid  growths,  202. 
fibroehondroma,  291. 
fihroliponia,  291. 

tibrolympliadenonia.  291. 
fibroma,  290. 

treatment  of,  291. 
l)ajiilloma.  290. 

treatment  of,  290. 

Cnreinonia  of  the  fauees,  ;5II. 

diagnosis,  .114. 

etiology,   .'il."?. 

patholopy,  .-Jll. 

profjnosis,  SIS.  • 

symptomatolofry.    .■•,1;?.  ; 

treatment.  :]](>.' 
e.xternal   o|)eration,   .SHI.  ' 

internal  ojjeration.  'Mn.  ' 

Carcinoma  of  the  nasopharynx.  229. 
Catarrh  of  the  na.so-pharvn.x,  I9r>. 
Chondroma  of  naso-pharvnx,  2.30. 
Chronie  pharyngitis,  237.* 
Clpft  palate,  "oporations  for,  454.  j 

Heplutition.  193.  • 

Perinoid  tumoi-H  of  the  pharynx,  202. 


Diseases  of   till'   u\  ula.  2.')2. 
o'dema  of  the  uvula,  2r)2. 
it  ioldjry,  2.")2. 

pldjrUdsis,    2.'i2. 

s.\  liiptoiiialdldir : ,  2.")2. 
Ir<al  III!  lit.  ■J.'>2. 
I  lonL'aiioii   di   I  he   uvula.   2."):!, 

elioldiry.    2.").'! 

patiidlo^.y,  2.");;. 
I'ni^riii.sis.  2.".4. 

-.\  lll|l|dllialdl(Jjry,      ■_>.-,} 

t'ealriieiit.  2.').'i. 


I'llirdina    di    iiasd  piiai-,  ii\,  22.'!. 
di:ii.'iid*is.  221. 

(I  lll|(l!.r^-     22.'i. 

palhdld^rv.   22;!. 

pn  j;iidsi.l.  221. 

•^.\  nipldm;itdldir\-.   22'l. 

Iiealiiieiil.   221, 

eokl wire   -narc.  22.'). 

elect ii, lysis.  22(1. 

.iralvanoeautery  ecrasenr,  22.") 
I'ibionii'  of  phaiynv'.  291. 
■•'olliclllar    phaiyii^ritis.  240. 
I'dii'ifju   bd.licsMi   the  fauces,  .'{21 

prd;.rnd>is.  .'!2.'{. 

iieatiiient,  .'!2.'t. 

Iliemorrha-e     follouinj;    toiisillotoniv 

2(!!». 
Hypertrophy  of  linpual  tonsil,  2S4 

di.ij.niosis.  2S7. 

etidldijy.  2S."). 

patholo^ry.  2.>^4. 

Jirdf^nosis,  2S7. 

syniptoniatol(ip\-,  2S(). 

treatment.  2.S7.' 
"perative,  2.S,S. 

Lacunar  tonsillitis.  272. 
Leukoplakia  palati.  ;!lo. 
r.inpual  tonsil,  hypertrophv  of,  284 
I. opus  of  pharynx,  297. 

diafrnosis,  29S. 

etioloiry.   297. 

|iath(plo;ry.   297. 

proirnosis.  .'{00. 

syiiiptomat(doj,'y,  297. 

treatment.  .'{(10." 

.Malijjnant    diseases    of    nasopharynx 
227.  •     ■  ' 

carcinoma   of  naso  jjliarviix,  229. 
symptomat(dopv,  229." 
treatment.  2:{0." 
sarcoma,  227. 

diagnosis.  227. 


Ki.s 


•  IIAKHAI.    IMiKX. 


:il 


I 


V<!; 


yi 


.  ..I. 


Malignant    ili^fU'.c'.    of    un-n  pliiirviiN. 
'^iHi'iiiiiii.  I'l ii)l<ij'\ ,  2'J7. 
|ial  liiiluj;\ .  'J-JT. 
|piiiMriii«is.  -Jjs. 

■.\  lll|ilii|ii,itci|ii;,'\  ,    1227. 

riTiitiiiinl.  J_'H.' 

Iiv   ^iiilviiiioiiuilri  \  .   .1J.U. 
Iliiswiirt  li'-  I'iisc.  22'.l. 
DcliiVitii's  CUM'.  li-JH. 
I.Kjfiiirs  ciisi'.  l!-J!», 
Mitli^iiiiiil,     di-t'!!*!'^     (i|     iii'ii  |i1kii  \ii\. 
.•!(I7. 

("llcillOlllil.    .'ill. 

siiicoiiiii.   I!(t7. 
IMycnsis.  |iliiM  \  ii;,'r;il.  :i77. 
ilia,i;iiii-i>.  '1X1. 
el  i(p|(ij.'y.  27'.!. 
|iiil  lin](i;,'y.   '277. 
|iriiL.'iiii..is,  'JS'J. 

>\  lll|)limiM|nj(i<|\  .   jsl . 
lll'iltllK'Ill.     ISl. 

Myiipiitliic  piiiiily^is  of  fauif>,  .'Mil. 
Myxotilprdina  nf  iia<ii  |iliaryii\.  'J 1 7. 

clia^'ncisi-i.  1\'.). 

(•ti(il(i;,'y.  -ils. 

|)atli(i|u!.'y.  -217. 

|ii(itrii'     i-^.   -If- 

-yili|ilii|iia1(ilii<i;y.  1  IS. 

ticaliiiciit.  •Jj'.l.' 

umisiial   (ascs.  -Jiil. 

Naf*ti-|)liaiyiij;<'al  calaiili,   l'-i.">. 

ilia<;iii)-^is.   I!t!l. 

el  i<)](>;_'y.    MMi. 

;ia).li(il(ij:y.    I!l">. 

|ii();;M<isis.    I'.HI. 

syiii]i1()iiialiiliii;y.    I'.IS. 

rn'atmciit.  i'.t'.l." 
Ni'\iri)scs  uf  llic  taiiic-,  .'!IS. 

iMy<i)iatlii('  ]iaralysis.  .'j1!>. 

iiiiiral^'ia  of  I  lie  jiliaryiix.  ;ils. 

iiciiriisis  of  iiiotioii.  ;il!t. 
of  'iciisation.   .'US. 

])aralysis  of  the  fauces.  I5I'.». 

OptM'atioiis  for  cleft    palale.    i't\. 

I'alato  -  f,'losso  -  iiliar\  iiL'eal      |iaral\^i-. 

.•{•2(t. 
I'liaiyufioal  inyeosis,  277. 
IMiaryiiireal   ))a])ilioinata,  I'Ml 
I'tiaryiifreal   iiilperciilosi-^,  I'X'i. 
IMiaryiifritis.  acute.  2.'! I. 
IMiaryiifiitis.  elirouic,  •j:!7. 

(liafrnoHis.  2.'i8. 

etiolofry.  237. 

patliolofry.  2117. 
is.  2:51 


pr<'K« 


:;{H. 


l'liar\  ii;.'it  i-.  cliroiiic.  ircatuieiii.  2.'{:t. 
riiar>  ii;.'ili-.   tolli.  ulai.  2  HI. 
ilia;;iiosi>*.  212. 
etio|o;^y,    24(1. 
|iatliolo^'y.  2411. 
|pro^iio>i>.  212. 
wyill|iloiiiatolo;.>y.  21 1 . 
tieatuielit.  2l.'<. 
I'ljarynv,  aiii.toinr  of.   Is."). 
Iiouiiilaiics  of.    |S.">. 
H|ieliili;r^    into.    |S."i. 
riiy-iolniry  of  |iliaryii\.   111.'!, 
-'oft    |ialate.    I!i:t.  ' 
loti-iU.    1!U. 

<.'Miii«y     oi    acute   tiiii-illil  i>.   24.">. 
iliaLrMo>i>.  2  IS. 
ctiolojry.    2>7. 

|iallioloi:y.  21."). 

|iro;;nosis.    2l!». 
>yiii|itonialo|(];iy.  217. 
trealiMcnt.  2l'.t.' 

lictio|ihaiy M;:cal   al)-le^^s,  2.">S. 
ilia;iiior,is,   2.")!l. 
etiology,   2')S. 
pal  lio|o;:y.  2.")S. 
|iliiL'tlo>i-;.   2l((t. 
*\  IU|ltolMato|ofry.    2.")!l. 

licalMiclit.   2IHI. 

Sareoiiia  of  the  fauces.  ."117. 
(Iiaj.Miosis.  .'!((S. 
ctiolo;,'y.  .'1(17. 
]iat liolo;jy.  .'ilt7. 
pro^riiosi-^.  ;i(t|l. 
syiu|)l<)inatolo;,'y.   .'{I}S. 
tiealliiellt.  MW.' 
Sta|iliyloirlia|iliy.  4.").'). 
Syphilis  of  the  pharynx,  .'iitl. 
(liafiMosis,  ,'5(14. 
efiolo;.'v.  3(»2. 
patholofJT.v.  301. 
))idf,niosis.  ,'!()"). 
syniptoniatolotjy.   3((2. 

ininiaiy.  'MVA. 

secondaix'.   3(1.'!. 

l4'itiaiy.'3()3. 
treatment.   .3(l."). 

ileforniities  of  pharyii.v,  3()(!. 

inucoiH  patch.  3<t.'>. 

ulceration.  3(l(i. 

Tonsillillis.  321. 
Tonsillitis,  ,321. 
Tonsillitis,  laetiiiar.  272. 


K 


syinptoiuatolofry,  23S. 


diafinosiS,  274 
I'tiologv.  27.3. 


\^:h 


7! 


fiRKKKAI,    INIiKX. 


1X1. 


\.  :?ot'.. 


'^'""Mllilis.   iM.Miur.   i,all,u|.,.rv    ■•:•' 

I'lo^nosis.  27 r>.  " 

••<yiii|)t()iiiiit()|(ijry_  27;{. 

•  I'iitiiicnt,    27.')'  ' 
T...iHil|„to„iy  I..V   tonsillotonM..  o.j; 

'•<'l<l-v.iii.  ,iiaic,  270. 

itii\<(l  s(i>siirs.  270. 

feMlvnii«ii:ml.T\  kiiitV,  "70 

loustls.    fiiiicijil.    nil 

liiij.'iiiil,    I!»2. 

J'li.ilyiijj:(iil.    I'M) 
i'o'isil,,   l.y|M.itn.,,|,v   u{,  •',;■> 
<ii;i;.'ri(isi.s.  2(m. 

fliill. )<ry,    2(14. 

patliolo.rv,   202 


!(;;» 


*yil||l|l)|||i,I,,|,,,rv.    204 

trcjitiiniit.   207"  '  " 
r«'inual,|f,  ,li«..a„..  2o;{ 
IuImiviiI,,,,.    ni  pliarvMN.  2W 

<iia;.'ri<i»i..  -lui, 

<'li<l|<)jr\  .    2!>.'{. 
I>al)|<l|ii^r\.    -t'Xl. 

jiri>jriii,*i,.  -ji)-, 

!'yill|)|.l||l.||ll|.,;..V.     2ii4. 

trfatirifiii.  2!»,") " 

I'laiioj.la^iy.   j.m; 
I  vula.  .luii^Mi,,,,,  „,•  ^,-.j 
"'di'iiia  .if,  2.V2. 


•^l^'Tlo.N     111.       I,,. 


;!!i,-, 


.•!o;!. 


:niH. 


''"■yiifjiUs,  371. 


-\lw..,s  of  tl..'  larviix 
Aeiitc  laiyiicrjiis.  •{(j.j 
(liajriicisis.  .'iO.'J. 

t'lioldjry.   ;j(i2. 
I>atil(.I(,(ry^    ;((;._) 

profrriosiis.  ;{(i4. 

^viiiiitoinaluldgv 
''■•'iifiiicnl.  ;i(i4.' 

A.ul..  huynfritis  of  cliihlivn 
Oiafjiiosis.  ;{t;,s. 

Pti()l(j<ry,    ;{(J7 

J)at.h()loory^  ;j(;7 
Jin.^rno.si.s.  .•{09. 
syniptoiiiatdlofrv 

tivadiiciii,  .soy" 

AcuU-  a'dciiiatoiis  I 
fliiipKisis.  .■!72. 

Pti.llofry.    ,<}7] 

I'iitfiology.   ;j7i 

I'fofrrio.sis.  .■J7;{. 
•"yinptoiiiatolopy.  :i:-> 
fnatiiicnt.  .•i74 
Affcction.s    of    tho    cri<.oarv( 

.  <iciiIa(ion,  ;5!Mi    ' 

Anicncaii   iicljulizcr    •.iH-> 
Anafoiny  of  (|ic  laiviix";!'; 
arteries.  .'i.-J."). 
Jirvteiioids,  ;{2!>. 
eriioid  eartilat^e    .'{'7 
nii^'Iodis,  ,330" 
lifraiiients.    3;{;{. 
Jyinphaties,  33"). 
miieous  iiipiiibrane   33", 
Jnu.sc'Ics,  3.35.  ' 

nfTve.s  of  larynx,  3.J,-) 
thyroid  cartilago,  3'^8 
vocal  cord,9,  333. 
Artfiritio    deformities    of    the 


mi. 


iioid 


ar 


laryn.v, 


KASNS    (,|-    11,,:    l,ui\\\, 

I    Mnijiliic  laiyii;,.iij..  .•{,S4. 

(Iia;r||n<j.    ;;s.-, 
,  lialliulojry.  .3s4. 

liru<;n.i-i>.  :ts.-). 

syiii|.|.,|„ai.ii,,;rv.  3s4 

tieatiiienl.  3>..v' 
J     .\llt<iscoj)v.   .•J.|.-, 

:        -<-"-.M,     f,„     autoUpi'"-.,.,,. 
j         '^''?;'.''"':  "•";:Me-depres,or.  345 

'  P<'S.llo„    ,„    antosenpy,    345. 

"•'"iff"  '^rn,  ,i,.  .,f  li.e  I;uynN.  420. 

<  ar.JMoiMa   of  the   larxnv    4.30 
'lia,!.'ii,,si,.   4;!.s.       ■ 

;  |iatll(dojry       j;>7 

profriioiii^.  4;{s_ 

Mlllptnui.it.ilnjjv      .|;j- 

li<a(rneiit.  4;5<)]'  ' 
-ndol.-uynfjeal   operation    .j;{., 

"""■"'•"i""    h-  .-rvsipela..    441 
larynj,'e,ton.y,   44(1. 

Sojis CoImii-^  operation    44(i 

>ordM,.  infenor  ,,y,;,Hn;, L^'^oo 

.;-.;..  Mennorrh...a' of  Stink:  S) 
<  iironic  laryngitis.  377. 

diarrnosi*. '37!t. 
}  etiology.   377 

pathology.  .'{77 
Iirognosi.-.  379. 

^vnipioniatologv.  37,S 

♦  itatinent.  .380" 
'left  palate,  operation  for.  420 

stajiliylorrhapliv.  455 

uranoplasty,  4.-;o. 
omniinutor  for  inhalations    383 
<  "ng.-n,tal  -ypl.ilis  of  laryi'x.  420. 


4TU 


•  ■KMiiAi,  rMii;\. 


I? 


%   ^ 


I 

IM 

■  l 

1 

-  ':  ■ 

i 

III 

Dilliciillics    in    laix  n;.'i;il    i  \;iiiiiii:ui"  ii. 

JlilFiiHO    piiclivdcnniii.  ;iSfl. 
J)is('u^<'s  (if  liirvMN,  ,'(2'). 

Filial  s|)ii-m  of  till'  liiiyiiN.  ■\.1\. 
J''il)i(p|iint!i  of  tlic  liir\ii'x,  42!'. 
loiii;;!!  Iicidiiw  ill  till'  liiiynx.  H.' 
(liajxiKi-i-i,    ti.'f. 

|iro;;ll(i>i>i,    H  I. 

-\  lll|ilci|lialo|oj;\  ,    ll.'t. 

tiiat  iiii'iil,   I  |."i. 

Ili>>loiy    <if   a    i-A-f    of    laiyii^rial    |i(ii-' 
chniiili  iii^,  ;i!t|. 

Iiihilial  inn,  ,'!.'il). 
infulialioii  liilif.    iiiiiini\ cd.   .'irili. 

ill  ili|ilil  liiria.  it.'i.'t. 

ill   lar_\  ii^'cal   si  rid  me.  .■!.'i;t. 
0'l)\\y<i""s  1  lilies.  .•),")!. 
o|i('iatioii  diiiiii;;  iiifaiuy.  ,'I."p1.  .'ire'. 

dmiii;,'  adult    life.  ;{."il'. 

iciiiovai  of  tiif  tiiiic,  ;{.■).•;. 


Kiist 


(■ill's  aiitosco|i('.  ;J4."). 


toiij,Mi<'-d('|iicssiir,   :{4ti. 

Laryiij:('al    nianifcstatioiis   of   i  lie 

tisiii.  ;i!)7. 
I.aryii<.'cal    )iciicli(Hidritia.   30.1. 
diii'MKisis,  .'i!l4. 


Ulna- 


['tiol( 
tliol 


."5!>:t. 


la 


"J-'V. 


;<»3. 

pi-of'liosis,  ;?!».■). 


syjiiiitoniatdlnpy,  D'l.!. 
ticatiiiciit.  .■)!•(!," 
F-ary Ileitis  liliiinosa.  3!t2. 
l.arynf,'i(is.  aciilc,  .'iU2. 
of  cliildrcii.  .'tfi". 
atid|iliic.  .■{S4. 
clirdiiic.  .'!77. 
(I'dciiiafon.s.  .')7I. 
tiiliciculav.  ;!!IS. 
I.aryii{j(isco|iy.  ;?4n. 

aiitlior'fi  opcratiiifr  (hair.   344. 
difliciiltii's  of  cxainiiiafioii.  ;i4'2. 
Iiosilion   of  ttic  ]iaticiit.  ;?44. 
I,('pi-osy  (if  tlip  air-]iassaj:cs,  4  Id. 
aiia'stlictii^  fiiini.  410. 
nodular   form.  410. 
T.cprosv   of  tho  nose.  411. 
larynx.  412. 

nioiitli  and  pliarynx.  412. 
troatincnt.  of,  414. ' 
T.upiis  of  llio  larynx,  40(i. 
diapnnsis,  407. 
jirofrnosis,  40S. 


I.ii|iii^  of  till'  laixiiA.  '■v  iiiptoiiialolopv, 
4t"7. 
Iiiatiiiiiil.    in.H. 

.Malignant  tumor.,  of  tlic  laiMix.  4:ifi. 

lii»to!ci;.'i(al  ('\aiiiination,  4;{(i. 
.Multiple  I'oiiiminiitor.    120. 
.Multiple  papilloiiiala   of  eliildicn.  4.'!). 

1  iial  mint    hy   traiiieotoiiiy,  434. 
iiil  iilial  ion.    t.'ll. 

N(  iMiii-  ajdioliia.    122. 

».\  iiiptomat(dot;\ .    122. 
I  real  mi  lit,  422. 
Neurosis  of  larynx.  421. 
sensation.  421. 
trealinent,  421. 
.Venidses  of  motion.   -12.1. 
diaLriio-is,   424. 
etiojoijy,   42.3. 
|,r.,jr||,,si<.    -pjl. 
-pa«m  of  ^^loltis.  423. 
-,v  niptomato|ii;fy,    423. 
Ileatlliellt.    42.">. 
N'on  nialipnant   tumors   of  the  larvnx, 
4211. 
i\~(omata.   4.'f(i 
eneliondidinata.  4.30. 
liliromatji.  42i>. 
lipnm.ila,  430. 
diafiiiosis.  431. 
pro^'iiosis.  432. 
sym|itomatiil(ipy,  430. 
treatment.  4.32." 
]iapill(iniata.  42!). 

flperation>  for  nasal  deforniities,  44!). 
.•\nnaiidale"s  450. 
Kllefs.  4.")0. 


J{( 


4:-)l. 


I'acliydermia  laryiij;is.  387. 

diafrnosis.  38S. 

did'usa.  3S7. 

eliolojiy.  387. 

]iaf li(il(i<;y,   387. 

projriiosis.  388. 

svniptomatolopv.  388. 

treatment,  .38!t." 

M'rrueoiis.  387. 
I'apillomala.   42!t. 
Paralysis  of  the  larynx,  420. 

otiolopv.  427. 

treatment.  428. 
Plivsioloirv  of  the  larvnx.  337. 
■  attrilnites  of  the'  33S). 

funetion  of  phonation,  338. 

funetion   of  respiration,  337. 

Senion"s  theory,  337. 


/ 


OENKUAL    INnilX. 


4ri 


I'MiiidipnicinliriMniuH  laryngitis,  31)1. 
riiurniit,  ."(iH. 
tiiniiiiatic,  :(JM. 


KcniDvnl      of      forci^fii      bodies      from 

ci'Sn|)|iiif,'lls,    148. 

l.iryn\,  4  !.'>. 
Kociitffcn's  rays  in   iaryiifrcai  siirfjcry. 
447. 
('Mioki'.i  tiilics.  417. 
siiayruph,    447. 


Siiiiplr  o'dcina  of  (he  laryn.x.  ;t7>">. 

diaf.'nosis.  :i7(!. 

('(i(il(i;;y.  '.U'l, 

|iallio|(ij,'y,  :i~'i, 

liroynosiH.   .'t7(;. 

syiiititoiiialoloiry,  ;!7,",. 

trraiincnl.  .■i7ti." 
Sulijflolti,.  cliionif  laryiiifitis,  ;1!»m. 
.Sypliiiis  of  llii-  larynx,  4iri. 

diagnosis,  417." 

otidlopy,  410. 

patiiolopy,  41.'). 

prognosis,  418. 

syniptoniatologv,  4)7. 


Syphilid  of  III,'  lai_\h\.  in.ii  im  m.  418. 
Syphililic   l,irMi;.'ial   stenosis.  4i!». 
Syphilis,    eon;.',  nil  a  I.    of    the     liirxrix. 
4-J(i. 

'rhyroloniy,  .'1,'iH. 

'Iiacl loiny.  .•f."i(. 

general   niia'sihi -i;,.  ii.-,.,. 
high    operation.    '.Wu. 
instriiMii'iit^  n«ed.  .'I.M. 
hieal  aiia-thi'sia.  ."I."!!;, 
low    opeiMlioii.  ;i,")h. 
'rniiereiilosis   of   the    JMi  V  ,i\.    .'lilS. 
diau'iio^i.-.,    liin. 
etiology,  ."KtS. 
patlMi|(i;.'y.    Hits. 

pro;,riiosi-.    1(»|. 

•<.\  ni|itoinMto|o;;y.    ;!<)!». 

IrealiMenl.    |nj." 
loiiira  •  indiealion-i    of    i  incKe- 

ineiif.  40;t. 
cliretteliient.    4l).{. 
suinnneoiis     iiiieetiini     in     treat, 

iiient.    in.!.' 
lraelieo(<iMiv   and    larvngectoni v 

4():!. 
(reatnienl    l,y   electrolysis,  4(i.'{. 

V'errneoiis  paehydermia.  ;{,S7. 


